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Beds in the Emergency Department Utilization Project, facilitated by Health Quality Ontario’s IDEAS Program


Over the last decade, patient volumes in the emergency department have grown disproportionately compared to the increase in staffing and resources at the Toronto Western Hospital, an academic tertiary care centre in Toronto, Canada. The resultant congestion in the ED has spilled over to the waiting room, where undifferentiated and potentially unstable patients must wait until a bed is available. The aim of this project was to decrease the 90th percentile of the time experienced by patients between triage and bed assignment (time-to-bed) by 50% for our highest acuity patients over three months, that is from 120 to 60 minutes. We engaged key stakeholders to identify barriers to and generate strategies for optimizing the flow of patients into the department. We tested eight plan-do-study-act cycles to address multiple flow-interrupting issues including operational and cultural causes. Strategies addressing communication breakdown were most effective: while temporary gains were achieved through the optimization of in-house digital information management systems, significant improvements achieved through the implementation of a low-tech direct contact mechanism (a two-way radio or walkie-talkie) were easier to sustain.  At the end of our project, time-to-bed for high-acuity patients had decreased from 120 minutes to 66 minutes at the 90th percentile, with special cause variation showing a significant shift in the weekly measurements. This measured improvement in the flow of our sickest patients was likely due to both the efforts of the project team as well as extraneous and environmental factors.


Lucas Chartier, Barb McGovern, Lucy Simoes
Team members: Meredith Kuipers, Kathy Bates, Jason Dickson, Steve Friedman, Sam Sabbah, Anil Chopra, Mary Kay McCarthy
Term of project: January 2015 – June 2015


​Project charter

Project presentation 

  • IHI National Forum on Quality Improvement in Health Care, December 6-9, 2015 in Orlando, FL

  • Health Quality Transformation, October 14, 2015 in Toronto, ON

  • University of Toronto Centre for Quality Improvement and Patient Safety (C-QuIPS) Symposium, October 8, 2015 in Toronto, ON

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