The high-pressure, high-stakes emergency department (ED) has some of a hospital’s greatest potential for improvement. Strides in clinical efficiency in the ED also provide an opportunity for better patient satisfaction and higher quality care.
Arrivals—or more to the point, wait times—are notorious for souring patient satisfaction (which can, through word of mouth, drive down volume), and shorter wait times are the linchpin for improving patient flow in the ED. Moreover, poor arrival protocols also are financially harmful; the penalties when patients are registered but then leave without being seen constitute significant losses of potential revenue for the hospital. In fact, reducing the number of patients who leave in this manner by even one patient per day can mean an additional $50,000 or more on the professional side and several multiples of that on the facility side.
Although there are a number of strategies for minimizing wait times and getting the patient in front of the right provider, there is a wrong way to do it: it’s called linear processing. And unfortunately, it’s been standard practice in many emergency departments for a long time. In a linear processing model, the patient endures one set of questions via the registration process, followed by two more sets of questions – first from a triage nurse and then from a primary nurse, before finally seeing the physician or advanced practice provider who likely will ask many of the very same questions posed earlier. The time spent on each of these steps and the time between them automatically draws out the arrival process unnecessarily, creating problematic bottlenecks for providers and frustration for patients.
Although this type of practice is common throughout medicine, there are alternatives to linear processing.
Parallel processing eliminates interviews that, from the patient’s perspective, do not add value and focuses instead on getting necessary physicians or advanced practice providers in front of the patient. This approach may require reorganizing space for patient intake and assessment. Because each patient is seen immediately by a clinician, non-emergent patients can be entered and discharged quickly, thereby making room for higher acuity patients.
A “care team” allows the ED to skip the triage step and immediately put a physician or advanced practice provider and a dedicated team nurse in front of the patient. Speed is one important concern with the care team approach. Another concern, and significant benefit of this approach compared to team triage, is reducing hand-offs and, with them, the errors that all too often occur during care transitions. Fewer hand-offs also translate into financial efficiency in terms of avoiding redundancies. One hospital reduced its arrival-to-provider time from over an hour to 13 minutes with the implementation of the care team model.
“Pull to full,” a simpler adjustment, means that patients are drawn into the ED until all beds are filled. This approach contributes meaningfully to improved patient satisfaction because it shortens the time they must wait to be pulled into the treatment area and be seen by the provider. By working to get the provider into the room to perform an assessment earlier in the visit, ED teams can much more quickly identify life-threatening illnesses, while reducing the likelihood that patients might leave the facility before being seen.
The in-room and disposition phases of the visit also should move efficiently to realize gains. In this portion of the visit, space is the limiting factor. To improve patient flow, EDs must move patients who are unnecessarily occupying beds out of those beds quickly. One way to do so is to get tests completed and results returned efficiently.
Waiting for lab testing and radiology is one of the chief causes for delays in the in-room process, so improvements should begin with measuring those turnaround times in relation to patient flow—and the “end” of the measurement should not be the time the lab obtains the result; rather, it should be the time the result is in the system viewed by the physician or advanced practice provider.
Some rules of thumb for increasing efficiency in these areas:
- Set aggressive goals for turnaround times.
- Monitor progress towards these goals (i.e., physician ordering, lab confirmation, lab results waiting, physician accessing results) automatically.
- In monitoring lab, radiology, and ED physician performance around these goals, make sure to check the outlying times as well as the averages.
- Adjust focus, and resources if necessary, to bring even the outlying turnaround times into range.
EDs tend to be most challenged with shifting from the traditional “stabilize and treat” to a “disposition first” orientation. Although stabilizing patients and providing appropriate care are indeed the governing principles of emergency medicine, unless there is a critical new patient, it is generally more efficient to make sure the disposition of existing patients has been effectively addressed before bringing in new patients. Clearing the physical and mental space to treat a new patient is easier when a stable patient is safely en route home or to the appropriate hospital bed
To realize the efficiency gains that can allow a larger volume of patients to be seen with the same amount of resources, the entire ED team must adopt and follow through on the in-room orientation toward disposition. As described above, even one extra patient seen per day without any additional resources could translate into additional professional and facility revenue gains of well over $100,000 per year.
Physicians naturally focus on patients who are newer or who have a more urgent need for care. But unless beds occupied by stable patients are vacated, those patients cannot be treated properly. Thus, having all ED staff adopt the “disposition first” mantra is critical. If possible, an ED could benefit from the appointment of a “bed czar” whose main responsibility is managing the ED’s beds, including predicting volume spikes, arranging bed readiness (i.e., housekeeping), and simply monitoring availability to stay ahead of the ED’s needs.
Somewhere between the culture shift toward disposition and the resource-reliant creation of a new position lies collaboration between the ED and the hospitalists who admit patients to the hospital. There is a traditional disconnect between these two groups, but even here, more efficient collaboration can be fostered through the establishment of specific admission protocols supported by both sides.
Establishing guidelines for the admission of patients from certain specialists is one example: Together, the groups could agree that the hospitalist service will admit for patients with gastroenterological conditions, with the understanding that hospitalists will consult on all such patients, as appropriate. Such protocols avoid the need for stressful case-by-case negotiations, minimize the time spent by both sides arguing or second-guessing a decision, and spare the ED physician from the need to make multiple phone calls. They also can address costly, dangerous errors that often occur around transitions of care.
Faster, higher-quality care leads to improved patient satisfaction, which in turn can lead to greater volume. Efficiently handling that volume can reap the very resources that help extend and sustain those gains. The story of financial efficiency in the ED is one that ends not only in more revenue for the hospital, but also, crucially, in higher-quality care for a greater number of patients.
Kenneth J. Heinrich is a senior vice president and group medical officer with Schumacher Clinical Partners, Chicago.