Patient Safety, 2010

Carilion Roanoke Memorial Hospital

January 2010

Carilion Roanoke Memorial Hospital, an 825-bed, nonprofit teaching hospital in Roanoke, Virginia, implemented AHRQ's Door-to-Doc patient safety toolkit after attending an AHRQ-sponsored training session in September 2008. This training was offered as part of an AHRQ Knowledge Transfer project. As a result of the training, the hospital emergency department (ED) has experienced a decrease in the number of patients leaving without being seen, a decrease in the amount of time it took patients to be seen by a clinician, and ultimately, an increase in revenue.

Prior to attending the AHRQ-sponsored training, Carilion was experiencing a left-without-being-seen rate consistently over seven percent, which had a negative impact on both patients and providers. Not only was the ED receiving complaints from patients regarding wait times, but staff members were also becoming increasingly frustrated with the delays in care. In order to decrease the left-without-being-seen rate, reduce the wait times in the ED, and improve employee turnover, Carilion began implementing Door-to-Doc in November 2008.

Since implementing the toolkit, Carilion has been able to reduce the number of patients leaving the ED without treatment from seven percent to two percent, enabling the ED to see more patients and increase patient volume from 190 patients per day to 205 patients per day. This increase in patient volume has resulted in a $156,000 increase in hospital revenue for every one percent reduction in the rate of patients leaving without treatment.

In addition, using Door-to-Doc allowed Carilion to reduce the wait times that less-sick patients spend in the ED from 228 minutes pre-Door-to-Doc to 186 minutes after implementation—an 18 percent improvement. In the Door-to-Doc model, patient flow is split into "less sick" and "sicker" patient subgroups. This determination is based on a brief analysis rather than a full triage. The system has the advantage of keeping the vast majority of patients—those who are less sick—moving during busy times, rather than waiting in the lobby or in the ED.

A key advantage with the Door-to-Doc model is that ED beds are reserved for sicker patients who truly need them. Less-sick patients, who tend to be ambulatory, are not assigned beds; instead, they move among treatment areas as they would in a clinic setting. These patients remain dressed and mobile as much as possible, and they wait for lab and other test results away from the flow of other patients.

Carilion's ED Practice Manager and Interim Director, Kim Roe, RN, attributes these improvements to the Door-to-Doc toolkit, which she considered particularly helpful for Carilion in terms of mapping out different scenarios in the planning stages of implementation. She says, "The split flow model and Door-to-Doc mindset has redirected our front-end process to better serve our patients. We were getting back-logged in triage, and the concept that not everyone needs a bed has really been helpful to us."

The Door-to-Doc toolkit, developed through AHRQ's Partnerships in Implementing Patient Safety program, was first pioneered as an ED patient flow innovation in Banner Health System's Mesa, Arizona, facility (since closed). The innovation was a change in process flow that Banner termed "Door-to-Doc."

Knowledge Transfer Case Study Identifier: KT-CQuIPS-30
AHRQ-Sponsored Activity: Partnerships in Implementing Patient Safety
Topic(s): Emergency Medicine
Scope: Virginia

Improving Patient Flow in the Emergency Department. Agency for Healthcare Research and Quality, Rockville, MD. February 2008. http://psnet.ahrq.gov/resource.aspx?resourceID=6689.

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