“Most of us have seen an increase in the number of patients we see per shift, and the new workflow has made it feel easier to achieve these numbers. We feel happy the patients are waiting less time to be seen, and it has improved patient safety and care.”  - Dr Tasha Haiduk, ED physician  

Janice Talarico, director, East Kootenay Regional Hospital, Lisa Jackson, manager, clinical operations access and flow (interim), and Melissa Schalla, manager, clinical operations (interim) at Interior Health Authority, alongside Drs Tasha Haiduk and Anneline Du Preez, initiated a quality improvement project that aimed to reduce high left-without-being-seen (LWBS) rates in the Emergency Department (ED) at East Kootenay Regional Hospital (EKRH) in Cranbook.  

They engaged MOBIA ED Flow consultants from Newfoundland who conducted an assessment and provided training sessions for ED physicians, staff, and leadership. Their assessment studied why patients were waiting too long for care and would leave the ED prior to being seen by a physician. Key findings from the assessment found that patient wait times were not occurring due to limited staff capacity, and discovered multiple factors that contributed to the ED wait time.  

The consultants offered a summary report with recommendations that led to the implementation of an ED Fast Track area, streamlined workflows, and increased engagement and a positive culture shift within the ED. 

Facility Engagement enabled the MOBIA ED Flow consultants and the multi-disciplinary team to work together to identify issues, share perspectives, and prioritize next steps to implement solutions.   

Impacts 

This project work decreased LWBS rates at EKRH significantly, shifting from one of the highest rates in Interior Health to near and/or below target rates (4%), which have been sustained for over one year.  

Other project wins include:  

• Improved physician initial assessment times.

• Decreased ST-Elevation Myocardial Infarction (STEMI) door-to-electrocardiogram (ECG) times.  

• Increased access due to more fluid and flexible space allocation in the ED. 

• New ideas generated to improve facility operations adjacent to the ED.

Streamlined workflows included trialling multiple approaches for paper flow and chart organization through Plan-Do-Study-Act (PDSA) cycles and implementing electronic tags in the ED tracker to indicate actions that need to be taken (i.e. New Orders, In Process, and Complete). Additionally, an ED Fast Track area was established that is staffed 12 hours a day by a licensed practical nurse trained in ECGs, as well as a hot seat doctor to reduce interruptions to physicians while they are working.  

The head of the department developed an Operational Action Plan in collaboration with ED physicians, which is now a standing item on monthly ED leadership meetings for discussion and implementation of ideas. Overall, the ED team feels more cohesive, engaged, and focused on continuous improvement.   

“There was an immediate and wide-spread physician and staff engagement and culture shift in the ED, the project work created an energy that was palpable.” – Lisa Jackson, Interior Health Authority  

Times to ECG for patients diagnosed with STEMI is more closely aligned with Interior Health targets (i.e. ECG within 10 minutes), meaning the ED team is very accurate in identifying suspected STEMI patients at triage and a dedicated stretcher provides the required space to allow for rapid diagnosis.  

The chart below shows how after the project interventions (red arrow), LWBS rates significantly dropped. 

Key takeaways and lessons learned:  

• Introducing too many new ideas at once can overwhelm staff, it’s important to focus on one change at a time and ensure continuous communication to reinforce and sustain the vision. 

• Some great ideas are limited by structural issues (i.e., existing staff levels, space, etc.), focus on what is feasible given your context and recognize some challenges are outside of your control (i.e. in-patient boarding as a big contributor to ED congestion and not within the ED control).