title: STEPS: lean thinking, theory of constraints and identifying bottlenecks in an emergency department.
abstract: This study aimed to identify the bottlenecks in patients' journeys through an emergency department (ED). For each stage of the patient journey, the average times were compared between two groups divided according to the four hour time frame and disproportionate delays were identified using a significance test These bottlenecks were evaluated with reference to a lean thinking value-stream map and the five focusing steps of the theory of constraints. A total of 434 (72.5%) ED patients were tracked over one week. Logistic regression showed that patients who had radiological tests, blood tests or who were admitted were 4.4, 4.1 and 7.7 times more likely, respectively, to stay over four hours in the ED than those who didn't The stages that were significantly delayed were the time spent waiting for radiology (p = 0.001), waiting for the in-patient team (p = 0.004), waiting for a bed (p < 0.001) and ED doctor turnaround time (p < 0.001).
authors.affiliation: Department of Public Health Medicine, Iona House, Ballyshannon, Sligo. aidana.ryan@hse.ie
authors.forename: A
authors.initials: A
authors.lastname: Ryan
authors.forename: K
authors.initials: K
authors.lastname: Hunter
authors.forename: K
authors.initials: K
authors.lastname: Cunningham
authors.forename: J
authors.initials: J
authors.lastname: Williams
authors.forename: H
authors.initials: H
authors.lastname: O'Shea
authors.forename: P
authors.initials: P
authors.lastname: Rooney
authors.forename: F
authors.initials: F
authors.lastname: Hickey
mesh_terms: D019091:Critical Pathways; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000592:standards*; D005260:Female; D006403:Hematologic Tests / Q000706:statistics & numerical data; D006760:Hospitalization; D006801:Humans; D007494:Ireland; D007902:Length of Stay / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D010348:Patient Care Team; D017064:Process Assessment, Health Care; D058996:Quality Improvement; D011859:Radiography / Q000706:statistics & numerical data; D013997:Time Factors