Improving Emergency Department Throughput for Patients With Vaginal Bleeding Using Iterative Plan-Do-Study-Act Cycles

In our Emergency Department (ED), the four longest arrival-to-room times among the 100 most common chief complaints were gynecologic: pelvic pain, vaginal bleeding in pregnancy, vaginal pain, and vaginal bleeding. In 2024, we recorded 3,584 ED visits for vaginal bleeding; 2,507 were nonpregnant, and 93.5% were discharged. Median ED length of stay (LOS) was 7.8 hours. These patients spend disproportionate time waiting and experience prolonged ED visits. We initiated a quality improvement (QI) project using a Plan–Do–Study–Act (PDSA) framework to address this throughput gap.

PDSA Cycle 1 tested the assumption that prolonged waits were driven by a prevailing belief that all patients with vaginal bleeding require pelvic examination, despite evidence that pelvic exams can be safely deferred in select low-risk patients. A low-risk vaginal bleeding pathway was developed to allow select non-pregnant patients to defer pelvic examination with expedited outpatient follow-up. Provider education, signage, and real-time prompting supported implementation. A five-month post-implementation evaluation assessed ED LOS and arrival-to-room time.

No statistically significant improvement in throughput was observed. Mean LOS for nonpregnant patients remained 6.49 hours pre- and post-intervention. Pregnant patient LOS increased from 4.95 to 6.26 hours without statistical significance. Arrival-to-room times were unchanged. Few patients met pathway criteria, and pelvic examinations were frequently performed despite eligibility to defer.

Encouragement to defer unnecessary pelvic examinations alone did not improve throughput. Pathway impact was limited by narrow eligibility and established clinical practice patterns. These findings prompted PDSA Cycle 2, focused on a structural redesign using a dedicated pelvic exam room to expedite evaluation. Ongoing assessment will determine whether environmental and workflow changes improve throughput for this high-volume, low-acuity population.