Technological Innovation Project:

Automation of ED Admission Orders

Angèle C. Wright
Frostburg State University
 Emergency Dept Patient Flow
Patient arrives
via AMBU or Patient
WALK diagnostics
(assessment,
labs, imaging) Discharge
Treatment w/ Follow
Up and/or
Reassessment Self Care
Disposition Instructions

Admission for
Patient is additional
transferred Bed Flow
searches for Orders are treatment or
to IP bed interventions
appropriate written, incl.
bed order for IP Patient is
bed type reexamined Hospitalist paged
by Hospitalist to write admission
orders
Background/Issue
 Emergency Department admits dozens of patients
on a daily basis

 Once the decision is made to admit a patient, care is

transferred from ED provider to Hospitalist

 Hospitalists have an hour deadline to reevaluate the

admitted patient and write admission orders
Background/Issue
 While waiting to be seen by hospitalist, patients are
held in Emergency Department treatment rooms

 Admitted patient cannot move to an Inpatient bed

until a Hospitalist places a physical order for an
inpatient bed type (Med/Surg, Telemetry, etc.)

 Patient flow coordinator does not search for bed

until it is ordered by Hospitalist
Background/Issue
 Admitted patient is typically frustrated by
prolonged wait to get to inpatient room
◦ Experiences two History & Physicals

◦ Long waits can undermine the patient’s trust in

healthcare team

◦ Expectation of moving quickly to an inpatient room

is not met leading to a misperception of poor care
received
Background/Issue
 Boarded admitted patients in ED leads to
◦ Inefficient Emergency Department patient flow

◦ Ambulance diversion to further hospitals leading to

delay in care

◦ Crowded waiting rooms and increased wait times

◦ Increased rate of sick individuals who leave the

Emergency Department without being seen
(McClellan, 2015)
Problem Statement
How can we streamline or automate the
current process to decrease the amount of
time an admitted patient spends in an
Emergency Department treatment room?
Technical Innovation Proposal
 Automate the Observation inpatient bed order
process

 Change EHR algorithm to simultaneously request

inpatient bed and send search criteria to bed flow
coordinator when patient is admitted

 Observation patient admitted under standing

orders and will no longer have to wait the
additional hour for Hospitalist
 Current v. Proposed Workflow
Observation patient admitted by ED provider.
Patient’s disposition logically changed to Admit
Hospitalist is paged to write
admission orders
Expectation within 60 mins of page
Hospitalist reassesses patient. Writes
admission orders, including IP bed order
Bed flow coordinator receives
order and searches for
appropriate bed
Patient is assigned to IP bed.
Expectation: transfer to IP unit
within 60 min
Report given to IP nurse.
Transport is arranged & patient
is transferred to IP bed
Observation patient admitted by ED provider.
Patient’s disposition logically changed to Admit
Proposed Change
Algorithm is written into EHR
A bed order is automatically transmitted to the
bed flow coordinator as soon as the patient’s
disposition is changed to Admit
Patient does not have to be seen by Hospitalist
Bed flow coordinator receives ED provider orders
order and searches for appropriate Standing
appropriate bed Orders for admission
Patient is assigned to IP bed.
Expectation: transfer to IP unit
within 60 min
Report given to IP nurse.
Transport is arranged & patient
is transferred to IP bed
 Project Timeline
Feb Mar April2 May June July Aug Sept
2017 2017 017 2017 2017 2017 2017 2017
Proposal to Process
Owners
Receive approval from
process owners
Implement algorithm
within EHR & test process

Train Process Owners &

Auxiliary Staff on new
change

Go Live with new process

Process Owners:
• Emergency Department Medical Staff
• Hospital Medical Staff Auxiliary Support:
• Nursing Informatics • Emergency Department Nursing Staff
• Corporate Leadership Team
Change Theory and Application
Kurt Lewin’s Theory of Change
 Driving Forces
◦ Patient safety
◦ Inefficiencies in patient flow
◦ Patient’s perceptions in care delivered
 Restraining Forces
◦ Current EHR infrastructure
◦ Extra capital to make changes in EHR
◦ Current practice
◦ Perceived need for change
 Equilibrium
◦ Currently equal
◦ Threat looms to push Driving Forces over Restraining Forces
Change Theory and Application
 Three Stages of Kurt Lewin’s Change Theory
◦ Unfreezing
 Convince process owners of benefit of change
 “What’s In It For Them”
◦ Moving to a new level or Changing
 Allows process owners to tackle feelings or thoughts
surrounding new change
 Training surround new change; new process reminders
◦ Refreezing
 Embracing “The New Normal”
 Encouraging and rewarding those who have adopted the
new process
 Summary and Expectations
 Continuous improvement
◦ In order to decrease the ED wait times, each part of the treatment
process has to be reviewed in order to decrease inefficiencies and
waste
◦ The change may be uncomfortable to those who own the process,
but ultimately, if it helps a patient receive faster care, then it is worth
the discomfort.

“You must be the change you wish to see in the world”

-Mahatma Gandhi
 References
Bernstein, S. L., Aronsky, D., Duseja, R., Epstein, S., Handel, D., Hwang, U.,
McCarthy, M., John McConnell, K., Rathley, N., Schafermeyer, R., Zwemer,
F., Schull, A., Asplin, B.R. (2009). The effect of emergency department
crowding on clinically oriented outcomes. Academic Emergency Medicine,
16(1): 1-10. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/19007346
Chahal, M., Khaira, A. (2013). Kurt lewin’s change theory. Retrieved from
http://www.nursing-informatics.com/N4111/KLewin.ppt
McClelland, M. (March 6, 2015). Ethics: harm in the emergency
department – ethical drivers for change. OJIN: The Online Journal of
Issues in Nursing. 10(2). Retrieved from
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/A
NAPeriodicals/OJIN/TableofContents/Vol-20-2015/No2-May-
2015/Harm-in-the-Emergency-Department.html
Shah, S.C., Patel, A.K., Rumoro, D.P., Hohmann, S.F., Fullam, F. (2015).
Managing patient expectations at emergency room triage. Patient
Experience Journal. 2(2): 31-44. Retrieved from
http://pxjournal.org/cgi/viewcontent.cgi?article=1090&context=journal