In the wake of Hurricane Harvey, Lyndon B. Johnson General Hospital (LBJGH) in Houston was forced to revamp their ED to meet increased demand—and the changes ultimately led its ED to be safer and more efficient than ever before, Kimberly Chambers, an assistant professor at the University of Texas Health Science Center at Houston, and colleagues write for Harvard Business Review.
Chambers, along with Jonathan Rogg, associate director of ED operations at the University of Texas Health Science Center, Kunal Sharma, medical director of LBJGH's ED, and Alan Vierling, EVP of LBJGH, write that Hurricane Harvey "caused significant moisture damage to [the hospital's] infrastructure," forcing LBJGH to close more than half of its 200 inpatient beds for months after the hurricane—even as ED volume rose by 7.5%.
Four changes that led to big results
To accommodate the increase in demand, LBJGH's ED implemented four major changes that, according to the authors, have led to very positive results.
1. To ease the shortage of inpatient space, condense the ED.
Because the hospital had shut down so many inpatient beds, the authors write, inpatient space was a key bottleneck in patient care. To address that problem, LBJGH converted an ED treatment area with 16 private rooms into an inpatient unit, which ultimately condensed the total square footage of the ED by 30%.
At the same time, the hospital repurposed unused spaces, such as hallway spaces and parts of the waiting room, into treatment areas.
2. To make efficient use of ED space, 'keep patients vertical.'
"With the reduction in the number of private treatment spaces in the ED, we identified that 'keeping patients vertical' was vital," the authors write. The hospital estimated that as much as 40% to 50% of the ED volume on a given day was comprised of patients that didn't require a bed to complete their care. As a result, LBJGH had patients who didn't need a private room stay seated in a chair during their evaluation, which allowed the hospital to keep private rooms reserved for the patients who needed them the most.
This change allowed the ED to care for more sitting patients and to see them quicker, expediting the ED process for patients who didn't need a bed.
3. To improve patient flow, create a low-acuity zone for patients awaiting test results.
Before the hurricane, patients typically waited until an ED bed was available before they received care, and that care was largely provided in the same physical space. But after the hurricane, the authors write, the hospital realized patients didn't necessarily need to stay in the same place and, instead, could be sent to a separate, low-acuity part of the ED that the hospital called "Results Waiting."
Despite about half of the ED's beds being closed, the authors write that the parallel processing change led to a decrease in wait times to see a provider and discharge wait times.
4. When you can't do everything alone, ask for help.
While LBJGH attempted to see every patient possible, the authors write that they realized they didn't have the capacity to see every patient who came to the ED. To address this, LBJGH created a process for transferring patients who could be better served in an inpatient bed to other hospitals in the area that had sufficient capacity. As a result, ED boarding hours were reduced to five-year lows, the authors write.
The changes to LBJGH's ED have stuck to this day, and have resulted in a:
- 52% drop in ED boarding hours;
- 29% drop in the number of patients leaving without being seen; and
- 22% drop in average wait times to see a provider.
The authors write that morale among personnel in the ED is also higher than it ever has been, and that the number of serious safety events in the hospital has declined.
"An often-referenced adage states: 'Never let a good crisis go to waste,'" the authors write, concluding, "At the Lyndon B. Johnson Hospital’s ED, we believe we took advantage of unique opportunities for rapid change imposed upon us by Hurricane Harvey and made improvements that have produced sustained benefits for our patients and our hospital" (Chambers et al., Harvard Business Review, 5/7).
Primer series: How to address avoidable ED utilization
Are specific patient populations making up a significant proportion of avoidable ED visits at your organization? In each primer, we profile organizations who have set up targeted programs and feature operational, staffing, and funding information.
- Right-size ED utilization for acute behavioral health patients
- Right-size ED utilization for complex care patients