Preparing for Patient Demand Under Reform: Does Your ED Need an Overhaul?
Lynn Massingale, MD,
Jason Hunt, MD,
Senior Leadership Editor
Robb White, RN, CEN,
Director, Emergency Services
Tomball Regional Medical Center
HEALTHLEADERS: Many of you have done some reengineering work in your EDs. How do you begin to create new systems and new capacity to meet increasing patient demand?
JONATHAN DAVIS: You can never fail by being efficient. What are all the touch points and how do we pull the team together both on the inpatient side and the emergency room side to make sure it's streamlined? I certainly don't have a crystal ball to forecast what the future looks like, but we are working diligently to provide the best-quality care, efficiently.
JASON HUNT: We recently consolidated our two emergency departments—making a 65,000-volume ED into a 100,000-volume ED overnight without adding bed capacity. So our focus was on improving efficiency as well. It was all about leaning up our processes as much as possible and looking at more creative ways of using available bed space. This primarily boils down to utilizing waiting room spaces for patients who have already been seen.
LYNN MASSINGALE: Our partner hospitals that are making the most progress seem to have certain things in common—most notably, that everyone shares in the responsibility of the final product. The ED team and hospital administration collectively admit there is a problem, and everyone takes responsibility for the problem while they work together on a solution. The hospital CEO really needs to focus on this, hold us all accountable and recognize progress, even if it's small progress.
ROBB WHITE: For us, the largest piece was putting together a team that works on the emergency department's operations and processes and getting those turnaround times really leaned out. When we got those down, we were able to see more patients more efficiently. We take ownership of the department and see a patient who has left without being seen as a missed opportunity, a failure of the emergency department and the hospital as a whole to meet that person's need.
HEALTHLEADERS: We've seen capacity concerns in Massachusetts, which has been covering its uninsured since 2008. Previously uninsured patients had been using the ED for their care and continue to do so, in greater numbers now. Will this be a problem at your facilities?
DAVIS: If more people have insurance and go to the ER, but we don't do anything to create family health centers and put more primary care into the community, absolutely. My goal is to have enough redundancy in the system that regardless of the circumstances, it will never fail. For example, we've implemented a QuickCare clinic on-site. It is staffed by physicians and mid-levels. Since 30% of our 70,000 visits are nonemergent, that's a great way to increase access to care. It's affordable, and you're not going through all the elaborate ER processes, saving those for true emergencies.
HUNT: On-site quick care is a great idea; however, it's important to make sure the public is educated that this is available for nonurgent problems to get them to self-triage, eliminating the need to shuffle people back and forth between quick care and the ER. We have a fast track as part of our ED that we run using a mid-level provider. It's seeing about 50 patients a day utilizing only two beds and its own small waiting area. We are looking to expand that in the near future. Doing so will help significantly improve some of our capacity issues.
MASSINGALE: Our hospitals also use fast tracks in the ER so we can treat lower-acuity patients using nurse practitioners or physician assistants at a lower expense, and we have some hospital-affiliated urgent care clinics. In addition, from an industry perspective, there is a great need for primary care and chronic care, and yet fewer and fewer physicians want to be primary care physicians. So something has to happen to primary care physician compensation to attract more people to primary care. I don't think hospitals can shoulder this burden indefinitely.
HUNT: Everyone who is discharged through our system goes through a single point. This area has dedicated nurses who are familiar with the community's resources, whether it's free clinics or dental clinics. They can also get patients financial counseling to get them signed up for Medicaid or other assistance. That way the next time we see them, hopefully they will have some form of medical coverage. It also helps the nurses in the treatment areas by taking this burden off them and helping to improve the turnover of vital bed space. They are able to do a lot of service recovery as well. This area has been a big success for us.
HEALTHLEADERS: Let's talk about process reengineering that you all have done to enable better throughput.
DAVIS: When I came into the organization, I heard that we had a 13-year-old problem. A lot of patients would leave when they stepped into the crowded waiting room. Our strategy was to capture the business that was leaving, so I pulled a patient access team together. I led that committee because of its organizational priority. We're approximately 225 staffed beds and we see 70,000 annual visits to our ER. If you look at other places that see that volume, they've got 700 beds. This was a systemic issue, not just ER. So in solving the problem, we had to look at the entire continuum from when the patient walks in to when he or she is discharged. The biggest struggle for our organization was getting through years of commentary and anecdotal nonfacts.
HUNT: We had outside consultants come in and see how much savings there would be by combining the two emergency departments. The physicians had felt for a long time that it was very inefficient to try to man two ERs literally steps away from each other. The challenge was to figure out how to move all of that volume into one box. So we visited a lot of other hospitals that were doing different things like putting physicians in triage and coming up with ways to move patients out of beds and into waiting spaces. We broke down all of our processes piece by piece. When you look at each step, you realize how much of the patient's time is wasted just waiting for the next step. The more things you can do in parallel, the better.
WHITE: We brought everybody together about three years ago and recognized that the processes that we had were noneffective at the time. As a community-based hospital, we still have some significant challenges with our community-based physicians and the limitations of that model. We've made significant process from evening rounds with evening discharges to actually making rounds at lunchtime and being in the hospital early in the morning and doing those discharges. The other side of healthcare reform is that, curiously, it has gotten community-based physicians to reengage and to recognize that it goes both ways. We had 20 or 30 cases in surgery on Saturday a couple of weeks ago, which is a pretty significant caseload for a Saturday for a community hospital this size. But that really helps with the ER, believe it or not, because those are surgery beds that are available during the week. It's rethinking patterns of work.
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