Implementing Real Time Unit Maps in the Emergency Department to Improve Patient

Turnover Time and Facilitate Patient Flow.

Leslie Martinez

Health Care Informatics Program, University of San Diego

Final Capstone Project

Faculty Advisor: Dr. Kathy Klimpel

May 15, 2023

 Abstract

This project aims to evaluate the implementation of real-time unit maps in the Emergency

Department (ED). The integration of real-time unit maps was brought about to help improve

patient safety, enhance the patient/ clinician/ staff workflow and decrease patient turnover time.

This paper will outline the key stakeholders participating in the integration, project timeline,

deliverables, and measures to consider post-go-live. Furthermore, the report will address

overarching issues in the healthcare industry, such as waiting room crowding and collaboration

among information systems and clinicians. Patients, clinicians, facilities staff, and information

systems will be the departments and individuals most heavily impacted by this implementation.

Thus, findings from this study will not only transform a workflow within a department but also

spark change amongst other departments and the healthcare industry in its entirety.

Keywords: Emergency Department (ED), Improvement, Patient Turnover, Patient Safety

 Implementing Real Time Unit Maps in the Emergency Department to Improve Patient

Turnover Time and Facilitate Patient Flow

Emergency department (ED) overcrowding is a common, global phenomenon that

negatively affects patient care, creates costly adverse effects, and disrupts patient flow. These

are directly linked to adverse patient outcomes and slower patient turnover times. By

implementing a real-time unit map across the various units in the emergency department,

clinicians and staff can significantly reduce the length of stay for patients on the floor as well as

ensure that rooms are turned over efficiently to maximize occupancy per room. Charles

Hammer supports this in the article, Enhancing Hospital - Wide Patient Flow to Reduce

Emergency Department Crowding and Boarding, by stating that the increase in inpatient bed

capacity can resolve the overcrowding in the emergency department and expedite discharges

(Hammer,2022).

Statement of Problem

The COVID-19 pandemic has created profound, long-lasting implications on patient

outcomes, the efficiency of resources, and technological advancements. Even after three years,

the United States healthcare system is still working to recover from the unprecedented

pandemic that altered the way clinicians provide care to patients. Busy waiting rooms and

unclear knowledge of patient room capacity have greatly affected the efficiency of healthcare

providers and placed the patient’s safety in jeopardy. Timely care and knowledge of resources

are vital factors every patient entering the emergency department requires. The Rady Children’s

Hospital, San Diego (RCHSD) Emergency Department was experiencing overcrowding in their

waiting room, lengthy patient turnover, and miscommunication among the facilities

management.

Population, Intervention, Comparison and Outcome (PICOT) Question

For staff in an emergency department, does implementing real time unit maps versus
static maps improve patient turnover time and facilitate patient flow over the first month after

implementation?

Literature Review

Studies indicated that in contrast to traditional care, unit maps were associated with

decreased in-patient mortality over five years for acute medical admissions, reduced length of

stay (LOS) on average by one day, and decreased waiting times for patient transfer from ED”

(Medical Assessment, 2013). Emergency departments (ED), in particular, face significant

challenges in delivering high-quality and timely patient care as many patients continuously enter

the department for care. With limited capacity in the emergency department and the growing

demand from patients, improving patient flow and implementing live maps was critical to

producing quality care and improved patient outcomes.

Improving Patient Flow and Reducing Emergency Department Crowding

Addressing the crowding issue in the emergency department (ED) should be at the

forefront of an organization's enhancement efforts, as a lot at stake could be compromised.

Emergency department crowding not only sends a message to stakeholders but also negatively

impacts the neighboring community's image of the organization. For instance, when patients

notice a crowded emergency department as they are approaching for care, they may feel

uncertain about the timely care they need. Then, a level of distrust is created between the

consumer and the provider. Nonetheless, this issue can easily be mitigated by improving patient

flow, real-time unit map implementation, and collaboration among departments (AHRQ, 2018).

The Impact Now and Future: Enhancing Hospital-Wide Patient Flow

One way to standardize processes and eliminate the crowding in the emergency

department is by measuring the effectiveness of the fundamental tool implemented and

analyzing the data collected. Findings from data and evaluations may point the problem in a

different direction and the overcrowding in the emergency department may be a sub-problem

that is a result of something else (Hammer, 2018) . Nonetheless, because the emergency
department is a high-risk, high stress environment, there is a lot at stake and many

opportunities for error. A patient's experience and safety cannot be jeopardized. Thus, this

reinforced the idea of needing multidisciplinary teams to work together on a task that impacts

multiple parties at once. Some benefits of a multidisciplinary team include different perspectives,

knowledgeable peers with varying expertises and more eyes to catch underlying causes

(Health, 2023).

Objectives & Purpose

During my practicum at Rady Children’s Hospital, Emergency Department, I had the

privilege of implementing unit maps for the emergency department, which provided rapid

physician assessment, decreased patient turnover time, and facilitated patient flow. The unit

maps were displayed in different zones of the emergency department to provide a snapshot of

the patient’s status and room availability. In addition, they showcased the layout of the rooms in

the emergency department. The committee ensured the patient and room information displayed

on these boards did not go against the Health Insurance Portability and Accountability Act

(HIPAA) regulations. All monitors were interconnected to show real-time edits and notes from

others in the same department. Staff and medical providers could write on the touch screen

monitor, rearrange the unit map view, and add virtual sticky notes. Medical professionals were

most interested in using the boards as a quick snapshot of patient status and demographic

information that did not go against the Health Insurance Portability and Accountability Act

(HIPAA) regulations. Meanwhile, facilities management used the unit maps to track clean, used,

and dirty rooms. Overall the real-time unit maps will improve the quality of care for patients,

patient safety and enhance organizational compliance.

Scope of Work

Before implementing the real-time unit maps in the RCHSD, Emergency Department,

there were some key stakeholders the planning committee needed to extend an invitation to for

participation. Ultimately, our team consisted of the Chief Nursing Informaticist, Clinical
Informaticist, Project Manager, EPIC Management, Workflow Specialist, and myself, a USD

HSON Informatics Student Intern. As part of the planning committee, we met weekly to

understand each other’s roles, draft an implementation timeline, set deadlines, schedule small

group meetings, and draft new unit map configurations. Our estimated total time to implement

the unit maps was six months, and the estimated total cost was $15,000.

Work Breakdown Structure (WBS)

The Work Breakdown Structure (WBS) includes five main categories: Project

Management, EPIC Management, Facilities Management, Clinical Informaticists, and

Information Systems.

Table 2:

Work Breakdowns Structures (WBS) for Planning Committee Members

Departments Involved Tasks

Project Management ● Define project scope

● Set budget for project
● Set expectations internally and externally
● Set bi-weekly sub-committee meetings
● Assign tasks to team members

EPIC Management ● Grant team members access to “test”

dashboard
● Evaluate build of unit map configurations

Facilities Management ● Provide scope of work

● Share workflow of managing multiple
spaces

Information Systems - Clinical Informaticists ● Create unit map configurations

● Research display monitors for unit maps
● Provide ongoing support to users.

Clinicians ● Share insight on current patient workflow

● Discuss the various aspects of charting
and admitting patients into a space/ room
● Test the implementation of real time unit
maps
Project Timeline

In total, there were six total phases in the implementation timeline. The first phase,

Planning and Designing, started on June 18, 2022, and lasted 105 days until October 15, 2022.

During this phase, we set expectations for each team member, scheduled weekly meetings, and

divided tasks that best fit every person's expertise and time commitment. The second phase,

Implementing, was ten days long, from October 15, 2022, to October 25, 2022. The planning

committee included the IT Specialist in this phase to support the software and hardware

implementation.

Additionally, in the third phase, Testing, from November 3, 2022, to November 15, 2022,

we started to test the applications and adjusted the clinical workflow where needed to integrate

the real-time unit maps. We also looped facilities management into the conversation to gain their

input on building the unit maps. After the Testing phase, we move along to the fourth stage,

Training. This stage lasted 15 days, from November 15, 2022, to December 1, 2022. During this

time, we worked on training superusers, nurses, and facilities management on how to engage

with the monitors and read the unit maps. In the fifth phase, Initial Go-Live, we launched the

real-time unit map configurations in select units. We started with smaller units and then

developed the unit maps for the larger units. Lastly, and perhaps the most critical stage, Post

Go-Live, consisted of evaluations and maintenance work.

Table 2:

Implementation Timeline for Real Time Unit Maps

Table 3:

Gantt Chart of Implementation Timeline

Deliverables

The unit maps were implemented in stages across the RCHSD Emergency Department.

First, the committee launched the finalized configurations of the unit map and worked on

installing touchscreen monitors in select units across the emergency department, starting with

the smaller units (Blue, Orange, and Yellow). Then, we trained staff on using all capabilities on

the touchscreen monitors, such as live notes and filters. The first iteration of the real-time unit

maps went live in mid-December 2022.

One month after the Initial Go-Live phase, staff in the emergency department noticed an

improvement in patient turnover time. There was less crowding in the waiting room and the real

time unit map monitors proved to facilitate patient flow well across the RCHSD Emergency

Department.

Conclusion

Implementing real-time unit maps can completely transform the patient experience at the

Rady Children’s Hospital, San Diego Emergency Department (RCHSD, ED). With live updates

easily accessible to clinicians and facilities management around the floor, the organization can
improve the quality of patient care and demonstrate its commitment to creating effective,

efficient patient workflows.

Next Steps

After implementation, there are still many conversations and valuable feedback to

consider. Some things to consider are performance measures, outcome measures, process

measures, system improvements, and user acceptance. Performance measures include

investigating software defects, reliability, data latency, and clinician workflow evaluation. Patient

outcomes and quality of care can help account for the outcome measures. Although I was away

to see the progress past the first iteration, I did receive some high remarks from staff members

in the planning committee. Nonetheless, I assume there will be continuous modifications on the

unit maps that satisfy the needs of clinicians working directly with patients in the emergency

department. Often, the more someone works with a new device and learns about its capabilities,

the easier it is to reimagine a process. Collaboration among informaticists and medical

practitioners is necessary to create a functional ecosystem where every user knows the

resources accessible to them. Lastly, evaluating the user acceptance of the unit maps can help

assess the success of the implementation. One way to collect user feedback is by distributing

surveys and allowing others to voice their concerns openly.

Future Recommendations

Providing quality training to staff members and enforcing collaboration amongst

members of different disciplines is crucial to the success of the unit maps implementation, as

well as the safety of patient information. Furthermore, by hosting training for staff members to

familiarize themselves with the functions of the unit maps, we will be able to maximize the

resources accessible and thoroughly evaluate the effectiveness of the implementation.

 References

Centers for Disease Control and Prevention. (2021, June 17). Covid-19 and chronic disease: The

impact now and in the future. Centers for Disease Control and Prevention. Retrieved

March 7, 2023, from https://www.cdc.gov/pcd/issues/2021/21_0086.htm

Hammer C;DePrez B;White J;Lewis L;Straughen S;Buchheit R; (n.d.). Enhancing hospital-wide

patient flow to reduce emergency department crowding and boarding. Journal of

emergency nursing. https://pubmed.ncbi.nlm.nih.gov/36084984/

Improving Patient Flow and Reducing Emergency Department Crowding. (n.d.). Retrieved

March 10, 2023, from

https://www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf

Medical Assessment and Planning Unit (MAP unit) reference paper. (n.d.). Retrieved March 7,

2023, from

https://www.health.qld.gov.au/__data/assets/pdf_file/0028/430597/mapunits.pdf
 Appendix A

Patient Check-In Workflow

 Appendix B

Capstone Project and Program Competencies

Leadership and System Management:

Leadership is practiced and developed over time. I do not believe that everyone leads in

the same way or that one way fits all as we all have varying communication styles and levels of

experience. I have appreciated learning from and working with nurses, teachers, paralegals and

data scientists throughout the program. They have each shaped conversations in the room

differently and contributed to my various projects. I enrolled in the Lean Six Sigma course in

Summer 2022 to help me develop new practices and understand new ways to implement

information systems.

Health Science Knowledge and Skills:

I first started taking classes in the HealthCare Informatics Program during the second

semester of my third year as an undergraduate student at the University of San Diego. One of

my first classes I enrolled in was Health Care Delivery and Systems which helped me

understand the patient processes, common medical errors, insurance policies and the current

state of information technology. One of my projects consisted of implementing a clinical decision

support system that helps alleviate the issues COVID-19 brought about. I proposed an

electronic COVID-19 vaccination verification and waiver to help streamline the check-in process

and clearly showcase which patients coming into a clinic are vaccinated.

Social Justice and Community Activism:

As someone who has a background in social work, community activism and received a

Bachelor of Arts in Sociology, I am passionate about equitable and accessible care for all. My

research and projects throughout the M.S Health Care Informatics Program were centered

around helping serve underrepresented and underserved populations such as people of color,

deaf/ hard of hearing individuals and unconscious bias’ we hold in the healthcare industry. Some
of my projects include the Rainbow Educators: Implicit Bias Training presentation, the Hear for

You project and Pandemic Preparedness Across the Health System.

Information Systems and Clinical Technology:

With no previous experience in healthcare technology or informatics, it was highly

important for me to understand the applications that help design electronic health records, assist

with data conversion and understand the way data becomes a tangible project plan for other

providers to act on. I learned how to code on SQL, participated in private Python sessions,

created tables on Excel spreadsheets and then created a project that showcased the usage of

information systems tools.

Data and Knowledge Management:

For this competency, I used the raw data from the COVID-19 clinic and practicum

placements at the Hahn School of Nursing to create a database project. I converted this raw

data on Excel, SQL and displayed my codes to the class in a presentation. From this finding I

was able to better store, filter and analyze the clinical placements at the Hahn School of Nursing

and Health Science.

Quality and Regulatory:

In regards to the quality and regulatory competency, I researched the CVS Health

organization and created a project that outlined the retail health services of CVS Health Minute

Clinic. I learned about the insurance plans under CVS Health, their new information technology

implementations, regulatory measures, and patient privacy measures.

System Design and Management:

The Nuance Dragon Ambient Experience: Enhancing Clinical Documentation (DAX)

presentation outlined the design, the features, benefits and limitations of DAX. In addition, I

evaluated the patient experience, patient outcomes and systems needed to maintain the new

developments.