Crowded emergency departments continue to plague the nation’s hospitals and the cost of poor service resulting from excessive delays can run into millions. Therefore, any attempts to ease ED crowding, reduce treatment delays and improve patient throughput can radically improve patient safety and a hospital’s bottom line — which makes the environment healthier for all concerned, including patients, staff, physicians and insurance companies. Because ED is the main entry point into these hundred million or even billion-dollar enterprises, it should always be important to improve access.
But, before any corrective changes can be made, hospital executives must understand the issues that cause delays and disrupt flow. Hospitals cite numerous reasons for ED traffic jams, among them:
. an aging population requiring more health care;
. staff shortages;
. inpatient bed deficits;
. uninsured patient use of ED for routine medical care;
. ED capacity;
. slow lab/radiology turnaround; and
. patient dumping.
These are all legitimate and real, but more fundamental reasons for overcrowding exist. Most of these are more manageable than hospital executives or staff believe and often improvement can be gained with relatively low cost adjustments in the management or practices. Even better, these changes can lead to not just improved efficiency, but higher quality patient care, and tremendous return on investment.
Actively manage demand surges
The typical ED lacks a management system for handling fluctuating demand. The very fact that so many hospitals have plans for handling catastrophic events like terrorist attacks is testimony to the ED’s inherent inability to manage fluctuating demand. These plans reveal the kinds of management processes and thinking that could help alleviate every-day demand surges.
Demand for ED services is, by nature, unpredictable, which makes planning for surges and quiet times problematic. At any moment in time, resources can be either overwhelmed or under-used. So, the trick here is to even out resource use. It sounds like a simple concept, but the ED culture is based on the need to respond quickly to crises, so, when the ED is quiet, there is less need for urgency and the staff tends to be more relaxed about completing tasks. Because the pace of ED operation is based on what exists rather than anticipating what might be, tasks that could be done in preparation for demand surges are put aside until they become absolutely necessary – which is most often during demand surges, when no one has time to do them.
In a crisis there is seemingly limitless energy to expedite tests or get patients moved up to the wards, or to get patients discharged. During quiet times, this energy is less evident. Why? It would certainly be advantageous to expedite patient flow irrespective of the condition in the ED.
Part of this management issue is based on ill-founded financial control efforts that focus on productivity. Scheduling schemes and rolling off personnel during quiet times depletes staff that could be preparing for the next surge. This is a penny-wise and pound-foolish management approach, because saving the $50 an hour rolling off an ED nurse for four hours may ultimately cost the hospital thousands in lost revenue when patients are forced to go elsewhere for care because of restrictions or excessive delays.
By anticipating and planning for demand surges, the hospital will not only generate more reimbursements, it can improve safety, morale, and patient satisfaction.
Reduce data overload
The health care industry tends to focus far too intently on clinical data and far too little on operational data. It lags behind other industries in using information technology for operational execution.
Too often when hospitals do try to invest in this technology, they go to extremes, with data requirements that would support every imaginable scenario or circumstance, demanding ‘just in case’ rather than real pragmatic requirements. The result? Huge, complex and very expensive systems, that are tough to manage and almost impossible to change. These become tools that, in trying to be all things to everybody, seldom deliver value to anyone.
The fact of the matter is, only a little information is necessary to keep things moving in the ED. With few exceptions, only three things — the patient’s acuity/status, availability of ED and inpatient beds, and the status of test results (not necessarily the actual results themselves) — are needed so that timely operational decisions can be made. The key is to provide the ED staff with the data needed to anticipate and act, rather than simply react, allowing them to prioritize activities and move patients through the ED to the next level of treatment or to discharge. Hospitals need to focus on getting the right information to the right person at the right time and under the right conditions.
Focusing on the basic data is what makes information technology an effective tool for the ED. Doing so reduces the need to assimilate and sort extraneous data, saving time and money, and, at the same time, speeding up patient throughput.
Build Trust in the Information
ED data problems are complicated by the hospital culture. Without transparency and integrity in the data, trust is lost among those who most need it for decision-making.
Clean, objective evidence is the seed corn of change and true data-driven improvement. Unfortunately, when the data is suspect, it is easily dismissed as inaccurate. From there decision-making moves away from the key issues and toward perception, experience, and the validity of the data. In any situation, especially one that is as complex and dynamic as in an ED, this is problematic because perception and experiences are truly individual. As such, it is not uncommon to see attempts to improve ED performance stall or get lost in a morass of opinion and infighting. The result is that the ED is labeled “resistant to change” and cynics reign over any attempt to resolve even obvious problems.
Engineering a system to produce trustworthy performance information will not only improve the chances of improvement, but can be the start of creating a culture of continuous improvement that is so critical to high quality health care and operations.
Recognize that special programs create unintended consequences
The best intentions can often lead to the worst unintended consequences simply because the entire hospital system was not considered in the conceptual stages of the change. The reality is that many of these programs look good only on paper. They are necessarily based on such statistics as average daily volume or average length of stay, but there are two big problems with this kind of analysis.
First, ED operations are exceptionally variable, so using averages has a great chance of resulting in poor conclusions. Second, yesterday’s average is based on yesterday’s conditions, yesterdays’ physician practice pattern, and yesterday’s inpatient mix. The only thing that is certain is that these factors will be different today and tomorrow. Anyone with ED experience knows that even subtle differences in the shift, the covering physician, the triage nurse, etc. can result in dramatically different operational performance. This dynamic is lost in the way special programs are created and deployed in the ED.
For example, establishing a chest pain clinic in the ED may answer a seemingly big problem, may be important to the local cardiology group, and should improve care and lower costs. But implementation means carving out specialized space and beds in the ED. During slow times for chest pain patients, the beds and clinical staff dedicated to that chest pain clinic go begging or get reassigned, in effect negating any advantage or worse, further restricting access for other ED patients.
In addition, misdirected problem solving such as adding capacity can have surprisingly negative consequences. Simply expanding the ED to ease overcrowding may not be the answer to improving throughput, when the real issue is lack of inpatient beds. The same goes for adding more radiology capacity, which might reduce the wait time for the x-ray, but does not address the delay after the test is completed.
Throughput occurs only when a patient actually leaves the ED. In a typical 4+ hour stay, there are many independent factors delaying patient flow, and these factors must be considered comprehensively. The variability in the time to get a patient triaged, in a bed, assessed, orders written, orders entered, tests completed, consults consulted, diagnosis completed, bed assigned, turnover report given, et al, combine to result in the actual ED length of stay.
There is a drastic need for systems thinking about the overall patient flow so that roadblocks to patient throughput can be quickly identified and addressed.
Align physicians and staff with the hospital’s mission and strategy
Unifying physicians and staff under one working plan can alleviate many of the problems that lead to overcrowding and poor patient management. A lack of alignment creates an inefficient and chaotic environment because people operate under different rules. These are multi-tasking professionals juggling four or more patients, with more on the way at any moment in time. They tend to set priorities based on their experience or perception and the circumstances that exist in real time.
While it is impractical to try to control the events occurring in an ED, it is very beneficial to standardize and control the RESPONSE to these events. Establishing operational protocols for ED is a step toward optimal efficiency. Developing and implementing criteria around such issues as ambulance diversions and inpatient bed placement, and then monitoring them for deviations, can build a cohesive hospital team that will provide an objective basis for continuous improvement.
It’s all well and good to identify these steps for stemming ED overcrowding and make recommendations for improvement, but facilitating and implementing the changes are what create real, lasting results. Hospital executives are buried in recommendations. Not only are the choices daunting, hospital resources for implementing them are limited to multi-tasking clinicians who don’t have the luxury of giving the effort their full attention. Without hands-on implementation that pulls people into the process of improvement and clearly demonstrates the value of the changes in real time, sustainable results will be fleeting at best.