title: Emergency Department Expansion Versus Patient Flow Improvement: Impact on Patient Experience of Care.
abstract: BACKGROUND
  Most strategies used to help improve the patient experience of care and ease emergency department (ED) crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both.
  
  
  OBJECTIVE
  To compare the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) on the patient experience of care in a medium-size safety net ED.
  
  
  METHODS
  This paper describes a study of a single ED wherein the department first undertook a physical expansion (2006 Q2 to 2007 Q2) followed by a reorganization of patient flow and establishment of an RAU (2009 Q2) by the use of an interrupted time series analysis.
  
  
  RESULTS
  In the time period after ED expansion, significant negative trends were observed: decreasing Press Ganey percentiles (-4.1 percentile per quarter), increasing door-to-provider time (+4.9 minutes per quarter), increasing duration of stay (+13.2 minutes per quarter), and increasing percent of patients leaving without being seen (+0.11 per quarter). After the RAU was established, significant immediate impacts were observed for door-to-provider time (-25.8 minutes) and total duration of stay (-66.8 minutes). The trends for these indicators further suggested the improvements continued to be significant over time. Furthermore, the negative trends for the Press Ganey outcomes observed after ED expansion were significantly reversed and in the positive direction after the RAU.
  
  
  CONCLUSIONS
  Our results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion.
authors.affiliation: Department of Emergency Medicine, Cambridge Health Alliance, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts.
authors.forename: Assaad
authors.initials: A
authors.lastname: Sayah
authors.affiliation: Department of Emergency Medicine, Cambridge Health Alliance, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts.
authors.forename: Melisa
authors.initials: M
authors.lastname: Lai-Becker
authors.affiliation: Department of Emergency Medicine, Lahey Medical Center, Burlington, Massachusetts.
authors.forename: Lisa
authors.initials: L
authors.lastname: Kingsley-Rocker
authors.affiliation: Department of Emergency Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.
authors.forename: Tasha
authors.initials: T
authors.lastname: Scott-Long
authors.affiliation: Department of Emergency Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.
authors.forename: Kelly
authors.initials: K
authors.lastname: O'Connor
authors.affiliation: Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Luis F
authors.initials: LF
authors.lastname: Lobon
mesh_terms: D064422:Ambulance Diversion / Q000639:trends; D003441:Crowding; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000706:statistics & numerical data; D005160:Facility Design and Construction; D006801:Humans; D065186:Interrupted Time Series Analysis; D007902:Length of Stay / Q000639:trends; D017060:Patient Satisfaction; D017064:Process Assessment, Health Care; D061665:Time-to-Treatment / Q000639:trends; D016312:Treatment Refusal / Q000706:statistics & numerical data; D014218:Triage / Q000458:organization & administration*; D057188:Workflow
keywords: ED crowding; ED renovation; diversion; emergency department; patient experience; patient satisfaction; total duration of stay