Hospitals are making a push to fix one of the most irritating issues in health care: the emergency room.
Armed with new research and strategies borrowed from the business world, some facilities are trying to ease the frustrating experience of waiting, filling out forms, explaining a problem—and then waiting some more.
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These pioneering hospitals model different ways for hospitals throughout the country to rethink the way they handle emergency care.
“There’s a lot hospitals can do that they haven’t done yet,” says Jesse Pines, professor of emergency medicine at George Washington University, whose research published in the journal Health Affairs in 2015 shows that on average hospitals have adopted less than half of the proven interventions they were surveyed about.
Adding urgency to the search for solutions: Not only are wait times dauntingly long, but they’re not improving at the national level. The median length of stay for patients treated in the ER and then discharged was 138 minutes, according to data for October 2015 to September 2016 submitted to the U.S. Centers for Medicare and Medicaid Services. Researchers analyzing wait times in 2006 found virtually the same median.
Long waits don’t just bring patient frustration. Crowded ERs and long wait times have bad effects for patient outcomes and satisfaction, research shows. For instance, it takes longer for patients to get pain medications, antibiotics or the care they need if they’re having a heart attack.
The overall evidence “paints a pretty clear picture that under more crowded conditions, quality of care declines,” says Benjamin Sun, an emergency-medicine physician at Oregon Health and Science University, who was involved in a study on ER wait times and strategies recently published in the journal Annals of Emergency Medicine.
Improving conditions on a wide scale won’t be easy. Researchers say there must be sustained management support to make changes stick. And many of these solutions don’t just mean reorganizing the way things get done—they also mean taking on additional staff, which can be a hard sell.
That said, many hospitals are seeing strong results from their efforts, and the movement is spreading. Here’s a look at some of the interventions that are helping make things smoother for patients.
Rethink (or eliminate) triage. One of the biggest frustrations people encounter in the ER is one of the first things they have to put up with: registration and triage. After signing in and giving information, patients see a nurse who asks questions to judge how urgently they need care and the amount they’ll need, on a five-point scale. Then patients wait to see a doctor who may ask them the same things all over again.
With the traditional triage and registration, “there’s no way a patient can get to a physician in less than 30 minutes, even if there’s nobody in the ER,” says Assaad Sayah, senior vice president and chief medical officer of Cambridge Health Alliance, a hospital system with many uninsured and Medicaid patients.
In 2006, Cambridge Health Alliance set up a system where arriving patients give their name, Social Security number or birth date, and chief complaint. They are then brought to a treatment area so a provider can start caring for them right away, and don’t have to complete registration until they’ve gotten that initial help.
Patients in the Cambridge Health system waited to see a provider for a median of 10 minutes, compared with a national median of 29 minutes for other ERs seeing a comparable number of patients, government data show.
Rich Petrik, the ER physician director for Ocala Regional Medical Center in Ocala, Fla., has adopted another strategy to cut repetition: having a doctor listen to the patient during triage and begin to formulate and execute a plan of care. After Ocala Regional Medical Center put that change in place last year, as well as other fixes, patients were treated and sent home a half-hour faster than before. (The results don’t include patients who were admitted to the hospital.) Other facilities have gotten similar results from rethinking triage, according to researchers.
Eliminate details that waste time. Another approach to streamlining emergency rooms comes from the world of business—the “lean” management system where an organization looks at every step in its processes and figures out how to improve them, cutting out as much waste as possible.
As part of the Canadian province of Labrador’s efforts to reduce ER wait times, the staff at Labrador Health Centre in Happy Valley-Goose Bay went through lean training last April with consulting company X32 Healthcare. Looking at their operations through the lean lens, the staff noticed that “supplies were kind of everywhere,” says Donnie Sampson, co-chairwoman of the regional steering committee for emergency-department improvement, who oversaw the hospital’s work.
So the staff collected the supplies in one room, giving the nurses only one place to keep stocked—instead of the previous five carts—and look for the items they needed. The staff also noticed nurses were taking time to escort patients to other areas of the hospital for testing such as X-rays, so they put up colored tape that patients could follow to where they needed to go.
Another big change involved how doctors and nurses communicate. The hospital set up whiteboards for nurses and doctors to write up the most current patient information for other staff to see, such as the status of test completion. Instead of walking around the ER to find another staff member to ask, the boards “allowed people to see flow without actually having to talk to another provider,” says Ms. Sampson.
Help patients with minor complaints quickly… One of the most widely adopted fixes to emergency rooms has to do with patients who have minor issues. How to make sure that they don’t face endless waits—and crowd ERs—while doctors are dealing with seriously injured patients?
Some 40% of hospitals in the U.S. are giving the people with small complaints their own spot in the ER. Labrador Health Centre’s redesign included an area where patients in need of a medication refill or with mild complaints like a sore throat could be seen right away by a nurse practitioner or physician dedicated to seeing only such patients. Seeing the low-acuity patients quickly means there’s “not a huge pileup of people in the waiting area,” says Wanda Slade, Ms. Sampson’s co-chairwoman, who oversaw similar changes at another hospital in Labrador.
Labrador Health Centre measured its average wait time to see a doctor for a representative week before the change for low-acuity patients and found wait times ran to nearly 3½ hours, Ms. Sampson says. In a representative week afterward, that average had been cut in half.
According to the research Dr. Pines published in Health Affairs, about 40% of hospitals had similar fast-track areas for minor ailments by 2010—and other research finds hospitals with these treatment spaces decreased patient wait times and overall length of stay.
…And those who probably just need tests. In addition to creating specialized areas to care for low-acuity patients, some ERs have begun to separate out patients who require diagnostic testing but appear well otherwise. In the old system, those patients get put in a bed—but that takes space from sicker patients, and involves a lot of cleanup to make the bed ready for the next person. So Kaiser South Sacramento has patients wait for tests in chairs or wheelchairs.
Having these patients lie down on a gurney would have “no real benefit,” says Karen Murrell, Kaiser South Sacramento’s assistant physician in chief for the emergency department and hospital operations.
Schedule elective surgeries evenly. A big cause of snarls in emergency rooms doesn’t have anything to do with emergency-room patients at all. It is patients elsewhere in the hospital undergoing elective surgeries such as knee replacements.
Doctors often schedule those surgeries early in the week so that patients will recover by the weekend (and doctors won’t need to look in on them past Friday). The result: Early in the week, elective patients take up a lot of hospital beds, and there’s no room for ER patients who have been admitted. So these patients must stay—or “board”—in the ER instead, reducing its capacity and bringing longer wait times.
The uneven surgery scheduling “creates a very unbalanced demand for inpatient beds,” says Dr. Pines. Boarding is “the elephant in the room when it comes to crowding.”
In a study of one emergency room, researchers from Boston University calculated what happened on days when the hospital had a typical number of elective-surgery patients and the maximum number of ER patients. They found that elective admissions added 35 hours to the total time all patients spent in the ER, in their findings published in 2007 in Annals of Emergency Medicine.
Some hospitals have chosen to schedule elective surgeries evenly throughout the week to avoid buildups. The strategy “sounds great in theory and has been proven to work,” says Dr. Sun, “but is very difficult to do because of physician preferences and culture.” Dr. Pines’s research showed that in 2010 less than 5% of hospitals had smoothed their surgery schedules.
Another way hospitals can release pressure from boarding is through rules dictating that boarding patients must be taken from the ER to inpatient floors to wait for a bed when the ER is out of space. That makes room for new arrivals and patients waiting to be seen.
After the Canadian province of Alberta instituted full-capacity protocols for its hospitals in December of 2010, boarding decreased by nearly half. What’s more, the time admitted patients spent in the ER decreased to about 11½ hours from an average of 17, according to research led by the University of Calgary and presented at the 2012 Society for Academic Emergency Medicine Annual Meeting. Although the admitted patients still wait for open beds, moving them to wait in another part of the hospital allows other patients to move through the ER more quickly.
Ease admissions from the ER to the hospital. When emergency-room patients are admitted to the upper floors of the hospital, getting them from the care of one medical team to another can be complex. Especially in a teaching hospital, the process can involve multiple conversations between ER staff and a medical student, resident and then the attending physician on the upper hospital floor.
Beginning in 2006, Dr. Sayah at Cambridge Health Alliance oversaw changes to get the ER and inpatient floors working together better. They cut the handoff down to one phone call to discuss the patient’s care. The handoff between nurses was also simplified down to a single phone call between secretaries for the ER and inpatient floor.
Meanwhile, even before the phone call is made, a nurse upstairs has seen a brief page of information about the patient and, barring any concerns that would keep the person in the ER longer, the patient will be moved in 10 minutes after the call. The system’s hospital in Cambridge, Mass., cut the average total length of stay in the emergency room for all patients to about 2¼ hours from nearly 3½ hours, according to research Dr. Sayah published in 2014 in Emergency Medicine International.
Anticipate backups with software. It can be daunting for harried staffers to keep track of how many patients are in the emergency room and how long they’ve been waiting. So some hospitals are using software to deliver real-time data on patient numbers—and advice on how to shorten waits as they’re happening.
Mercy, a 44-hospital health system in Arkansas, Kansas, Missouri and Oklahoma, is using data collection and analysis software from health-care analytics company Qventus in nine of its ERs, and plans to roll out the program in another. The system monitors data including how many patients are in the ER, how urgently they need care, and how many patients are waiting to be seen or to go to a bed in the hospital. It also takes into account expected patient volume from historical data, as well as possible upward spikes from factors such as weather.
With all that information in hand, the system can predict when the ER will run out of capacity and alerts staff a few hours in advance, via text or another messaging mode. Staff members have specific tasks to do after they’re alerted, like accelerating the completion of lab and imaging tests and getting patients who have been either discharged or admitted where they need to go.
Qventus doesn’t direct treatment decisions, but it can recognize patients who have been waiting a long time and are likely to leave, then nudge staff to check in. The system can also recognize when lab tests or imaging studies for a patient haven’t been completed in a timely manner and alert the doctor or charge nurse before the patient has been waiting for two or three hours.
Mercy’s emergency room in Fort Smith, Ark., its first to adopt Qventus, in the summer of 2015, has reduced the average time patients wait to see a doctor by 15%, to about 60 minutes from the previous 70. The hospital also cut the average time patients spent in the ER before being discharged by about 23 minutes, to just under three hours.