Improvement of emergency department patient flow using lean thinking.

Objective: To apply lean thinking in triage acuity level-3 patients in order to improve emergency department (ED) throughtput and waiting time.

Design: A prospective interventional study.

Setting: An ED of a tertiary care hospital.

Participants: Triage acuity level-3 patients.

Intervention(s): To apply lean techniques such as value stream mapping, workplace organization, reduction of wastes and standardization by the frontline staff.

Main Outcome Measure(s): Two periods were compared: (i) pre-lean: April-September, 2015; and (ii) post-lean: April-September, 2016. Variables included: median process time (time from beginning of nurse preparation to the end of nurse finalization after doctor disposition) of both discharged and transferred to observation patients; median length of stay; median waiting time; left without being seen, 72-h revisit and mortality rates, and daily number of visits. There was no additional staff or bed after lean implementation.

Results: Despite an increment in the daily number of visits (+8.3%, P < 0.001), significant reductions in process time of discharged (182 vs 160 min, P < 0.001) and transferred to observation (186 vs 176 min, P < 0.001) patients, in length of stay (389 vs 329 min, P < 0.001), and in waiting time (71 vs 48 min, P < 0.001) were achieved after lean implementation. No significant differences were registered in left without being seen rate (5.23% vs 4.95%), 72-h revisit rate (3.41% vs 3.93%), and mortality rate (0.23% vs 0.15%).

Conclusion: Lean thinking is a methodology that can improve triage acuity level-3 patient flow in the ED, resulting in better throughput along with reduced waiting time.