Emergency Services. Time Study

Transcription

1 Prepared for: Peter Forster Management Systems University of Michigan Hospitals December 18,1991 by: Associate Hospital Administrator Emergency Services Ann Arbor, MI Don Suffivan Jeremy Roberts Lisa Clayton Industrial and Operations Engineering 481 Project Time Study Emergency Services University of Michigan Hospitals

2 Table of Contents Page Executive Summary i Introduction 1 Purpose 1 Project Scope 1 Data Collection Methodology 2 Figures 1 and 2 3 Current Situation 4 Hypothesis 4 Findings and Conclusions 5 Figures 3 and 4 6 Figures 5, 6, and 7 8 Figures 8 and 9 9 Recommendations 1 Appendices A: Data Collection Procedures 13 B: Timecard 14 C: Supporting data and graphs 15

3 Executive Summary Management Systems was asked by the Emergency Services department to conduct a study analyzing the process followed by patients requiring a plain film radiological examination. This study was requested to aid in the Emergency departments ongoing pursuit of improving the quality of emergency care. The r emergency area of the hospital is composed of three units, all of which were monitored: Urgent Care, Pediatric Walk-in, and Emergency Services. The study captured the entire visit of patients requiring a plain film radiological exam, with special attention given to the interaction between the Emergency Service areas, University Hospital Radiology, and Mott Radiology for selected children. Other services performed in the emergency areas were not analyzed. The methodology used to address this problem involved the determination of fundamental time intervals within the x-ray process and the collection of data characterizing these intervals through the use of timecards and punch clocks. Data was collected over a four day period, twenty-four hours a day from November 14-18, This time period covered two weekdays and a weekend. Currently, bottlenecks in this process are causing unnecessary delays in patient stay, thus negatively affecting the quality of care provided by the hospital. Overall, the process lacks effective communication links that would keep both the emergency and radiology areas informed of patient care progress. The formal data collection portion of this study determined time statistics which describe the basic intervals of the plain film radiological process. Overall the x ray process took on the average 8 minutes throughout all shifts. In Emergency Services this accounted for approximately 3% of the overall patient stay, while in Urgent Care this time accounted for 7% of patient stay. Looking at the pediatric patients that had plain film examinations conducted at the main radiology facility, the x-ray process accounted for 5% of their overall visit. Forty percent reductions in patient stays were experienced by those patients whose x-rays were ordered through triage as compared to patients whose x-rays were ordered by an emergency physician. Individually, the average times for each process interval seem reasonable, yet an overall time of approximately 8 minutes from the time the requisition is written until the results of an x-ray reach a physician is lengthy and causes a substantial delay in patient care. Deviations between shifts have also been observed. Overall patient stays in Emergency Services are significantly longer during the day with an average [i]

4 stay of 298 minutes. Evening visits are on the average 7 minutes shorter while night visits are approximately 5 minutes shorter, yet each shift served the same number of patients. Through analysis of the data and observations made, we have generated a list of recommendations which should be considered by the Emergency Services department to decrease the length of time for the results of an x-ray to reach the emergency physician. Expansion of the emergency area alternator room The layout of the alternator room is currently adding to the time delay due to its small size and overall disorganization. Consequently, the expansion of the emergency alternator room facility is recommended. A larger area would allow for proper and more efficient information control systems. One solution to this problem that should be explored is the possible conversion of part of a waiting area located adjacent to the alternator room. Staff Teach-in Currently the overall x-ray process is not sufficiently understood by the emergency area staff. This lack of knowledge is contributing to the inefficiency of the process. Staff members are unaware that when a patient has been returned from radiology this implies their film has been posted; therefore, it is recommended that a teach-in be prepared for the entire staff in emergency and radiology. Cooperation and communication between the emergency areas and radiology would also be enhanced due to this increased knowledge and understanding of each others responsibilities. Initiation of X-ray Process in Triage The data demonstrates that patient stays are significantly shorter when the triage nurse initiates the x-ray process; therefore, when appropriate it is recommended that triage nurses write x-ray requisitions. Time intervals According to the data, the time intervals from registration to the time the x-ray requisition is written and from wlen the emergency physician has the x-ray diagnosis to patient discharge from the emergency area are lengthy. it is recommended that the emergency department look into other frequently performed functions occurring during these intervals in further studies. Staffing Issues Due to large variations in overall patient stay among shifts, it is recommended that the issue of optimally coordinating staffing levels with workload be reviewed by the emergency areas to further improve patient care. Radiology Utilization - A recommended area of future study is an analysis of the percent utilization of the UHS radiology rooms. This study would help address the question of the necessity of expanding radiological services in order to further shorten patient stay. [iii

5 Introduction The Emergency Services department of the University of Michigan Hospitals is currently searching for ways to reduce the time that a patient spends in the emergency room. One area of possible improvement focuses on the process followed by patients who are in need of a plain film radiological examination. To address this problem, Management Services conducted a study analyzing this process. The cooperation and help provided by all hospital staff made this project possible. The following describes the methodology and results of that study. Purpose The purpose of the study was to analyze the emergency visit with particular attention paid to those patients requiring plain film radiological services. By analyzing fundamental time intervals within this process, we have identified bottlenecks and formulated recommendations for improvement. By decreasing patient throughput time, the emergency area can improve the quality of its services, as well as alleviate visitor frustrations. Project Scope The emergency area of the hospital is composed of three units, all of which were monitored: Urgent Care, Pediatric Walk-in, and Emergency Services. The radiology process studied is only slightly different in each area. This study measured relevant time intervals starting from patient registration and ending at discharge from the emergency area. Data was collected at various points in the process in order to analyze the effects of each step on the entire process. A flowchart of the entire procedure was established to standardize the process. This was done to provide a useful format for future administrative analyses, and to enhance departmental understanding of the overall process. The study captured the entire visit of patients requiring a plain film radiological exam, with special attention given to the interaction between the Emergency Service areas, University Hospital Radiology, and Mott Radiology for selected children. patients seen in Pediatric Walk-in require x-ray examinations that should be Some conducted with the help of a pediatric radiologist. In these cases the patient is sent to the Mott radiology facility for examination. Other services performed in the emergency areas were not analyzed. [11

6 Methodology The most critical task was collecting useful, definable, and consistent data to represent the time duration between the elemental intervals in the process. Thus, our goal was to locate natural check points within the current system that would standardize the process, thereby allowing us to capture fundamental time intervals which would serve as a basis for process improvement. Interviews were conducted with various hospital staff to gain a thorough understanding of the process, and the variations that occur between shifts and among the three Emergency Service areas. Data collected from these initial interviews revealed natural break points in the system and allowed the x-ray process to be flowcharted in detail. Two process flows were determined and can be seen in the following figures and timecards that can be found in Appendix B: Radiology Area Patient lnitiatinq Area UHS Mol Emergency Services Urgent Care Pediatric Walk-in Figure 1 Timecard 1 Figure 1 Timecard 1 Figure 1 Figure 2 Timecard 1 Timecard 2 The methodology used to capture the defined checkpoint times was based on these flow charts. The collection process utilized timecards that were punched in time clocks located in the three emergency services and radiology areas. These timecards were attached to the back of the x-ray requisition forms. At the completion of each interval, the time of occurrence was recorded by a staff member who punched the card in a specific slot on the time card. Complete descriptions of the procedure followed at the end of each time interval can be found in Appendix A. [2]

7 [3] Radiology leaves for Registration Called-in Patient written Time Order Emergency Services = UHS Radiology process Figure 1. Flow chart of Emergency areas/tjhs Radiology process. Figure 2. Flowchart of Pediatric Walk-in/Mott Radiology process. Physician Order = Pediatric Walk-in = Mott radiology diagnosis diagnosis film & gives or retrieves rime Radiologist Mofl reception Patient Time Mott written Time Time arrives in Time quisition Exam room 4 Called-in Patient retur Exam begins to PED Walk-in 2 Patient Requisition Registration lees for Time 3 Time 1 diagnosis Alternator Zives Films posted cian Radrologist Time reviews film arrives in Tim Time [ Patient

8 Training sessions to familiarize staff with the collection process were conducted with the nursing staff in the emergency areas as well as all affected members of radiology. The data collection technique was tested by a pilot study prior to implementation. Problems and participant suggestions were identified by the pilot test and used to refine the process. Data was collected over a four day period, twenty-four hours a day from November 14-18, This time period covered two weekdays and a weekend. Project members were available on pager 24 hours a day, and in person at every major shift change throughout the entire study to answer questions. Current Situation Currently the procedures used to direct patient movements in the three emergency service and radiology areas follow the process described in Figures 1 and 2. Imperfections in this process are presently causing unnecessary delays in patient stay, thus negatively affecting the quality of care provided by the hospital. The process described in the exhibit does not entirely reveal the complexities that occur in reality. During hectic times and during off shifts when staffing is not maintained at the same level as during the day, standard procedures are often not followed, and the resulting process can be characterized as inconsistent and random. The hospital staffs lack of clear understanding of the entire x-ray process also contributes to process inefficiencies. Currently, the process does not promote effective communication between the emergency area and radiology. The process lacks effective communication links that would keep each area informed of patient care progress. Hypotheses Originally Considered Possible problematic areas and recommendations to solve them were considered before data collection. The feasibility of these alternatives were to be explored through data collection and analysis. Considerations that were given before the study are the following: Eliminating any unnecessary steps in the process. Expanding the x-ray services available to the emergency areas. If the volume capability of radiology is judged through analysis to be inadequate for the emergency services case load, this alternative may be the only solution to improve the quality of emergency care. [4]

9 Inadequate staffing levels during off shifts were identified as a potential problem. Significant deviations in average times when data is broken down by shifts would signal this as a problematic area. No mechanisms are in place to inform the emergency physician that film is waiting in the alternator room. Furthermore, there may be an overall communication problem between the emergency physicians and radiology. Findings and Conclusions The formal data collection portion of this study provided significant time statistics which describe the basic intervals of this process. Overall the x ray process took on the average 8 minutes throughout all shifts. Emergency Services this accounted for approximately 3% of the overall patient stay, while in Urgent Care this time accounted for 7% of patient stay. Looking at the pediatric patients that had plain film examinations conducted at the main radiology facility the x-ray process accounted for 5% of their overall visit. Forty percent reductions in patient stays were experienced by those patients whose x-rays were ordered through triage. These patients were not forced to wait to be seen first by a physician, thus the -1 time interval was in effect eliminated. at triage. Currently only 1% of the x-ray requisitions are initiated Figure 3 shows these intervals and their corresponding mean times of completion for the Emergency Services area, Urgent Care, and Pediatric patients seen at the main radiology facility, while Figure 4 shows mean times for examinations completed at the Mott Facility. In Individually the average times at each interval seem reasonable, yet an overall time of approximately 8 minutes for steps 1-7 through UHS Radiology is lengthy and causes a substantial delay in patient care. The length of the arrow suggests the work content directly required to complete the step. The thickness of the arrow suggests the time in that step, i.e. thin lines imply rapid completion. These statistics are presented in greater detail in the appendix. In that section you will find distribution analyses of the interval times, shift breakdowns, and data from the Pediatric Walk-in and Urgent Care departments. Figure 5 illustrates the mean time and standard deviation of each step in each of the emergency units seen through the UHS radiology facility. can be seen from this figure that high standard deviations appear consistently throughout all data. This randomness is inherent in an emergency care unit It [5]

10 t=63 Time t=3..3 t=16..3 Time 1 Time Time 2 Requisition Order written Patient Registration Called-in leaves for Radiology Time t=12 t=19 t= Time Time t=19 Discharge 7 6 Physician Radiologist Time reviews film reviews 5 or retrieves film & gives Films posted diagnosis Alternator t=6.3 Time 4 Patient arnves in Exam room Q = Emergency Services = UHS Radiology process Figure 3. Emergency Services/UI-IS Radiology process mean times (minutes). t=47 t=3 Time Time Time 1 Time 3 Requisition t=7 written 2 t=9 Patient Registration Order leaves for Called-Tn Mott t=13 Discharge Q = t15 Time Physician. t=2 reviews film 6 or retrieves Time Radiologist diagnosis 7 reviews Time film & gives Patient returns diagnosis 5 to PED Emergency Exam begins Pediatric Walk-in = Mott radiology Time 4 Patient arrives in Mott reception Figure 4. Pediatric Walk-in/Mott Radiology process mean times (minutes). [61

11 due to the rapidly changing environment. Large time delays are seen in interval 5-6 for all three areas with an average of 17 minutes needed to have the film read by a radiologist. It is also seen that the time in interval -1 in Urgent Care is significantly lower than the other emergency areas. This may be due to differences in standard procedures between units. As summarized in Figure 6, significant deviations exist between shifts in Emergency Services. The time interval required for a radiographer to pick up a patient in the emergency service area to take to radiology is largest during the day. A higher workload and a larger number of patients that are not ready at the initial pick-up may be two primary reasons. Overall, the patient is not ready for transport to radiology 1% of the time with an average delay of 2 minutes. Consistency between shifts was found between the time to call in an order and the time to start the exam after patient pick-up. These standard events are not greatly affected by work-load or staffing variations. The time interval from the start of the x-ray exam until film posting is longest at night possibly due to a reduction in radiographers present at this time. The time delay required for the resident radiologist to read the film during the night shift is highest possibly due to the fact that at this time there is not a radiologist posted specifically to the emergency alternator room. Overall patient stays are significantly longer during the day with an average stay of 298 minutes. Evening visits are on the average 7 minutes shorter while night visits are approximately 5 minutes shorter, yet all shifts service approximately the same number of patients. As seen by analyzing the radiological portion of the process (intervals 2-6), the time required for these steps remains fairly constant at approximately 8 minutes throughout the three shifts. Possible reasons for varying overall patient stays include heavier workload, inefficient staffing levels, or inadequate examination facilities. Figure 7 presents the mean and standard deviations of the Mott/ Pediatric x-ray process intervals. It can be seen that overall patient stays are shorter for pediatric patients seen through the Mott radiology facility with an average of 146 minutes as compared to an average of 176 minutes for patients examined through UHS radiology. Figure 8 represents the actual x ray process (steps 1-7) and the radiological section (steps 2-6) of the process as a percentage of the entire visit for patients seen through the main radiology facility. Figure 9 presents this same information for the Mott radiology facility. [71

12 Mean Time/Standard Deviation in Minutes of Process Time Intervals. November 14-18, 1991 All N = # of patients studied in Initiating Unit patients sent to U.H.S. Radiology unless otherwise noted. Process Time Interval Initiating Unit N Otol lto2 2to3 3to4 4to5 5to6 6 to 7 7 to 8 to 8 Em. Serv /59 3/8 16/17 6/8 22/29 1 9/35 1 9/3 12/115 25/13 1 Pediatrics 17 67/33 5/6 1 2/25 19/1 2/15 15/14 5/6 16/ /52 Urgent Care 8 27/16 2/3 8/17 13/5 11/7 15/5 8/17 37/39 121/51, Initiating merg. Serv. Shift Process Time Interval N Otol lto22to33to44to5 Sto6 6to7 7to8 Oto8 7 a.m.-3p.m /63 4/1 19/15 6/1 24/23 21/21 15/13 13/ /151 3p.m.-1 1p.m. 35 5/48 5/4 1 6/23 7/6 16/12 21/18 23/36 91/ /17 llp.m.-7a.m. 21 5/62 5/6 17/12 6/7 28/5 56/92 22/31 63/63 247/14 Process Time Interval for Patients being sent to MQTT for Radiological examinations Initiating Unit N Otol lto2 2to3 3to4 4to5 Pediatrics 1 47/27 3/5 9/8 7/3 1 /7 5to6 6to7 7to8 8togIOto9 2/12 15/11 22/18 13/8 1146/39 UHS Radiology time intervals Q Registration Films in 5 alt. room 1 Req. written 6 2 Called in Rad. reads Dr. receives 7 dlagnosis/ 3 Pat, leaves reviews film for Rad. 4 Exam 8 Discharge starts Mott Radiology time intervals (J RegistratIon 5 Exam starts 1 Req. 6 Pat. leaves written Mott 2 Called in 7 Pat, arrives at Peds. Pat. leaves 3 for Mott 8 Dr. receives diagnosis Pat. arrives 9 Discharge at Mott [81

13 Combined Intervals of Process Time Represented as % of Total Time. November 14-18, 1991 All patients sent to U.H.S. Radiology unless otherwise noted. Combined Intervals of Process Time Initiating Unit or Initiating shift of Em. Serv. tol + 7 to E lto7 2to6 Em. Serv. 66% 34% 25% Pediatrics 53% 47% 28% Urgent Care 33% 67% 39% 7 a.m.-3p.m. 7% 3% 24% 3p.m.-llp.m. 65% 35% 26% llp.m.-7a.m. 46% 54% 43% Combined Intervals of Process Time for Patients sent to MOTT for Radiological examinations Iotol+8to911 to8! 2to7 Initiating Unit Pediatrics 41% 42% UHS Radiology time intervals o Registration Films in 5 alt, room 1 Req. written Rad. 6 reads 2 Called in Dr. receives 7 diagnosis/ 3 Pat. leaves reviews film for Rad. 4 Exam 8 Discharge starts Mott Radiology time intervals Registration 5 Exam starts 1 Req. 6 Pat. leaves written Mott 2 Called in 7 Pat. arrives at Peds. Pat. leaves 3 for Mott 8 Dr. receives diagnosis Pat. arrives 9 Discharge at Mott [91

14 Recommendations Through analysis of the data and observations made, we have generated a list of recommendations which should be considered by the Emergency Services department to decrease the length of time for the results of an x-ray to reach the emergency physician. The following recommendations include changes and issues that should be explored further for future process improvement. following: The recommendations include the Redesign Emergency Services alternator room Staff teach-in Triage initiation of x-ray process Analyze (-1) and (7-8) intervals Staffing issues Radiology exam room utilization Expansion of the emergency area alternator room The layout of the alternator room is currently adding to the time delay due to its small size and overall disorganization. The time intervals 5-6 and 6-7 are currently being adversely affected due to this problem. Data has demonstrated that unnecessary patient delays are occurring because of these two time intervals. The room currently can only accommodate two people, one of which must stand. One seat is provided with a small ledge acting as a desk for the radiologist to write his report. No mechanisms such as in/out baskets are present to control the flow of films in an organized way. The atmosphere of this room is uncomfortable due to the cramped quarters, and thus discourages physicians and other staff members from frequently checking for x-ray progress. The small size also hinders information flow due to the fact that staff members must wait to get into the room if it is currently being occupied. Often the disorganization of the area hinders people from obtaining the information they need in an efficient manner. Consequently, the expansion of the alternator room facility is recommended. A larger area would allow for the proper information control systems, and thus the organization of the area would be largely enhanced. The efficiency with which information can be obtained from the room would therefore be increased. A larger area would also decrease the length of the time interval 6-7 due to the fact that more people could utilize the facility at one time. One solution to this problem that should be explored is the [1]

15 possible conversion of part of a waiting area located adjacent to the alternator room. The alternator room should be enlarged to accommodate up to 5 people, expansion of desk space, and the installation of shelves or some other film control mechanism. Through expansion, resource sharing delays would be eliminated. Staff Teach-in Currently the overall x-ray process is not sufficiently understood by the emergency area staff. This lack of knowledge is contributing to the inefficiency of the process. The time delay in the interval 6-7 is increased due to the fact that staff members are unaware that when a patient has been returned from radiology this implies their film has been posted. If emergency physicians were aware of this process step it would act as a signal that the film is available for viewing. As discussed earlier, there is currently no mechanism which provides this knowledge to the staff; therefore, the physician must randomly check the alternator room for his patient s film. It is recommended that a teach-in be prepared for the entire staff in emergency and radiology, and that this short discussion be repeated each month for new residents that rotate into the area. Due to the brief amount of time that is necessary to achieve an understanding of the process, this recommendation would not interfere with the staffs schedule, but would have a significant impact on the length of patient stay in the emergency area. Cooperation and communication between the emergency areas and radiology would also be enhanced due to this increased knowledge and understanding of each others responsibilities. Initiation of X-ray Process in Triage The data demonstrates that patient stays are significantly shorter when the triage nurse initiates the x-ray process. It is therefore recommended that triage nurses write x-ray requisitions when appropriate instead of waiting for the patient to be seen by a physician. Time intervals: Registration - Requisition written (-1) Physician has diagnosis - Discharge (7-8) According to the data, the time intervals (-1) and (7-8) are lengthy. It is recommended that the emergency department look into other frequently performed functions occurring during these intervals. These intervals [11]

16 contribute significantly to the length of the overall patient stay. The remaining 7% of the patient s stay in Emergency Services, 3% in Urgent Care, and 5% in the Pediatric area is accounted for by these two intervals. Possible areas of improvements may be found by analyzing the standard operations performed within each. Staffing Issues Due to the large variations in overall patient stay among shifts, it is recommended that the issue of optimally coordinating staffing levels with workload be reviewed by the emergency areas to further improve patient care. Radiology Utilization - A recommended area of future study is an analysis of the percent utilization of the UHS radiology rooms. This study would help address the question of the necessity of expanding radiological services in order to further shorten patient stay. [12]

17 - 7. Appendix A Data Collection Procedures from training handout prepared for staff: l. Time Zero- This data point is manually recorded on appropriate paperwork by registration. This data will later be transposed onto the time card upon discharge. 2. Time One- The triage nurse/nurse/physician - whoever writes the 3. Time Two - requisition, will punch the attached time card. However, this time may just as easily be recorded manually onto the time card in the appropriate box, but please use the wall clock in unit to verify time. radiology. 4. Time Three - The clerk at the desk will punch the card as the order is called into A radiographer will pick up the requisition on the clerk s desk and punch it in a time clock placed on the desk. This is to be done whether or not the patient is ready to leave for radiology or not. exception: Pediatric Emergency& Urgent care- this time is recorded by the nurse/clerk at the time the patient is directed to Radiology. 4. Time Four- A time clock will be placed at both radiology posts. Card punched 5. Time Five - by radiographers just prior to giving the exam. Time clock positioned at the alternator, radiographer to punch card when film is dropped off. 6. Time Six- The Radiologist will punch the time card upon reviewing the attached films to make a communicable diagnosis. Time Seven- The physician must punch & remove the time card from the requisition at the time of retrieving the written diagnosis or at the conclusionary reviewing if a written is not done. 8. Time Eight - This time will be written onto the time card manually by the discharging nurse, also Time Zero will be recorded here too. the time of / Cr [13]

18 V Appendix B Time Card 1: Main Radiology Facility Time Card 2: Mott Radiology Facility I i I Patient Dept. Ped U.C. E.R. Requisition Written by: Triage Nurse Physician Q Registration 1 Req. written ) Called In r3. leaves r Rad. i I Exam 44 starts 5 FIlms In alt. room 16 Rad. reads 7 Dr. receives dfagnosis/ reviews film S of films Patient Requisition Written by: Triage Nurse Physician Q Registration I 2 Called 3 Pat. Req. written In leaves for Mott 4 Patient arrives at Mott S Exam starts of 5 Pat.leaves films 7 Pat. arrives at Peds Dr. receives 8 dlagnoslsl reviews film I (3 DIscharge ieatment Orthopedic consultation: spllnt_ phone cast exam Radiologist consultation [14] cj Discharge Treatment splint cast Orthopedic consultation: phone exam Radiologist consultation

19 Appendix C Supporting data and graphs follow on the remaining pages. [15]

20 : Exam begins 3: Patient is transported to X-Ray exam room 2: Order is called-in to Radiology IntruIc.process intervals of plain film radiological examinations I II E. 8.Mean Interval Times Combined shifts: Emergency (main) 8: Patient is discharged from ER. 5: Films of exam are posted at alternator 6: Radiologist reviews/diagnoses film 7: Physician retrieves diagnosis 1: Requistion for radiological exam is initiated time : Registration in Triage

21 E : Physician retrieves diagnosis 8: Patient is discharged from ER. 6: Radiologist reviews/diagnoses film 2: Order is called-in to Radiology Interyjils a) I 14 1: Requistion for radiological exam is initiated time : RegistratiOn in Triage process intervals- plain film analysis..mean Interval Time Day shift: Emergency (main) 3: Patient is transported to X-Ray exam room 4: Exam begins 5: Films of exam are posted at alternator

22 Mean Interval Time 2: Order is called-in to Radiology 3: Patient is transported to X-Ray exam room 4: Exam begins 1: Requistion for radiological exam is initiated : Registration in Triage Intervals I z C 6 U, C) Evening shift: Emergency(main) 7: Physician retrieves diagnosis 5: Films of exam are posted at alternator 6: Radiologist reviews/diagnoses film 8: Patient is discharged from E.R.

23 Mean Interval Times lnferglc 14 - Night shift: Emergency (main) 2: Order is called-in to Radiology 3: Patient is transported to X-Ray exam room 4: Exam begins 5: Films of exam are posted at alternator 6: Radiologist reviews/diagnoses film 7: Physician retrieves diagnosis 8: Patient is discharged from E.R. C, ( 1: Requistion for radiological exam is initiated time : Registration in Triage

24 3 Distribution: interval ( to 1) registration - requistion Emergency (main)-combined shifts minutes 1 1 ave= 62. I. K T:. -, - I I I - I V 2 Count

25 Distribution: total visit time wi plain film Emergency (main)- all shifts 7 6: k rn I aue= 23 mm. : sample count 1

26 15 Distribution: E.R. interval (2 to 3) call-in to pick-up patient 1-5 minutes ave=16 - i! L ) Count 15 Dist: T (4 to 5) I arrival (x-ray) - alternator 1 5- minutes ave=22 rn. ) V Count

27 Dist: T (5 to 6) alternator- radiologist diagnosis *less outliers* 8 I, minutes count 2 1st: T (6 to 7)- radiologist reviews- physician receives : minutes..a

28 rj wi plain film ave. = 27 mm. Emergency (main) w/plain film Distribution: day shift- total visit E C, ivr th vvv V aue= 19 mm. Distribution: Evening shift - total visit

29 7 alternator (4 to 5) 1 2 w:j aue= 24 mm. ave= 16 mm. 3 4 ::: arrive in X-Ray to alternator Distribution: Day shift - (4 to 5) interval a) C E C E 1 d\j\}avij arrive in X-Ray to Distribution: Evening shift- interval A Id 4

30 Dist: Nite shift - Total visit wi plain film aue= 2 mm Count 1st: nite shift- interval (4 to 5) arrival in X Ray to alter tor ave*= 18 mm Count

31 aue. = 27 mm Dist: day shift- total stay Emergency (main) U, 4, E 2 -

32 dist: day shift - interval ( to 1) E 1 aue= 79 mm. : 2 O O dist: day shift - interval (7 to 8) i:o aue= 13 mm. 2 Count

33 dist: day shift - interval (2 to 3) 8 -, C, E EA aue= 1i.v. 19 mm. 4 Count dist: day shift - interval (4 to 5) 15-, 1, C C E j J:JJ. aue= 24 mm. I

34 dist: day shift - interval (5 to 6) 1 8, 6 D 4 2 aue=21 mm Count dist: day shift - interval (6 to 7) 6 -, a, 4 - C E 2 aue= 15 mm. 1 2 Count