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Emergency Department Throughput: Recognizing and Addressing Five Common Inhibitors

Lynn Massingale, MD, FACEP, for HealthLeaders News, December 7, 2007

In the context of emergency medical care, waiting is dangerous, frustrating and costly. Whether patients are critically ill or seeking non-urgent care, the success of any emergency department (ED) hinges on its ability to deliver efficient, quality care in what is frequently a fast-paced, stressful environment. A well-coordinated ED can lead its hospital to improved patient care, enhanced public image and a larger share of the market, while an ED that suffers from poor throughput - the inability to register, treat and either admit or release patients efficiently - can compromise patient safety, customer service and hospital viability.

The high cost of poor throughput
Poor throughput is an impediment to quality care, and long wait times are both exasperating and risky for patients. It goes without saying that people who are ill do not like to wait for attention. Patients who become frustrated in your ED are likely to remain frustrated throughout their hospital stay, setting the stage for low patient satisfaction and a negative perception of your facility in the community. More importantly, even when triage does not reveal a high-acuity condition, all patients benefit from prompt treatment as it prevents further deterioration of their physician condition in the waiting room. Long wait times have routinely been correlated with negative outcomes.

Poor throughput also negatively impacts the economics of your hospital. The ED accounts for roughly half of admissions to most hospitals and is responsible for a large portion of their revenues. EDs with long wait times nearly always experience patients leaving without treatment, many of whom have urgent needs and many of whom are demographically attractive to the hospital. If three to five percent of patients leave without treatment over the course of a year in an average-volume ED, the result is hundreds of thousands of dollars in lost revenue to the hospital.

Five tricks of the trade for ED throughput
While many factors can inhibit patient safety, patient satisfaction and financial viability in the ED, poor throughput is a usual culprit. Improving efficiency is the clear but not simple solution. Five common inhibitors of ED throughput plague hospitals nationwide. While there are no easy answers or quick-fix solutions, experience shows that creative problem solving can lead to major improvements in these five "must not fail" areas.

1. Boots on the ground
A young child sits in the waiting room with worsening flu-like symptoms and no physician available to him. A middle-aged woman is ready for discharge from an ED bed but waits 45 minutes after the doctor says "you're ready to go."

Nothing impacts patients like prompt, frequent contact with caregivers. Many American hospitals are struggling to fill positions with qualified applicants as the well-documented physician and nursing shortages sweep the country. How can we meet staffing needs most appropriately to optimize throughput at affordable cost?

Idea: Determine PRECISELY when, what time and in what quantity your ED requires physicians, nurses and mid-level practitioners. Map patient flow with strict intensity, seeking the most complete picture of patient arrival times, patient acuity and both percentage and type of hospital admissions. This process requires more than charting daily numbers and dividing by 24 hours. It is an exact science that can divulge nearly everything you need to know about scheduling the proper ratio of caregivers for optimal performance including throughput.

2. I promise
A physician orders a blood workup, but lines get crossed and no one arrives to draw it. Frightened of needles, the patient waits in angst. A urinalysis is ordered and drawn at noon but is only delivered 2 hours later to the frustrated sole physician in the ED.

Lab and imaging can be the strongest allies or the biggest barriers in your campaign for ED efficiency and prompt throughput. Engaged technicians serve a critical role in the patient care process, but those who become disconnected and disenfranchised can be a wrench in the gears.

Idea: Create a written contract of expectations between the ED, lab and imaging departments. Sit down with leaders and staff in those departments and discuss reasonable turnaround times for common processes. Set aggressive goals together and commit to them. The important thing is that this is more than just a conversation - it's a promise. Celebrate any tangible improvement towards your goals by arranging a personal visit to the ED, lab and imaging departments from senior hospital leadership (read: CEO) to congratulate their hard work. And, when performance starts to slide, do not hesitate to voice your dissatisfaction. After all, we're all in this together.

3. An on-call "Band-aid"
On one hand, a hospital boasts level one trauma care, but, on the other hand, there is no ophthalmologist for miles. An urban hospital has a rolodex of qualified cardiologists, but all three local hand surgeons refuse to answer calls because they're tired of giving uncompensated care.

As demand for on-call pay rises and competition for certain specialties stiffens, your hospital may be feeling the pressure to secure the services of qualified specialists. Transferring patients to other facilities is often risky, sacrifices revenue and can be just as time-consuming as tracking down specialists in the first place.

Idea: While you continue to work to permanently solve on-call shortages in some way, assign an enthusiastic, persistent, non-clinical staff member the responsibility of contacting on-call specialists needed in the ED. Physicians, nurses and mid-level practitioners don't have the time, energy or patience to perform this task. More often then not, they have to do it anyway. Rather than confining caregivers to phone duty while sick patients sit in the waiting room, hire someone with a winning personality to develop relationships with area specialists. Obviously, the emergency physician will discuss the case with the specialist once he or she is contacted, but simply finding them distracts caregivers from throughput tasks. As many EDs have noticed, tracking down specialists is nearly a full-time job on some shifts.

4. Know which business we're in
EDs are outpatient facilities.they're not in the inpatient business! They screen sick patients, stabilize them and send them where they need to go. However, when there's no physician on hand to admit a patient, or hospital beds aren't available, patients often remain in the ED- sometimes for 48 hours or more.

Not only does boarding (or holding) patients in your ED hinder the patient care process, it effectively shrinks the size of your facility. On a busy night, this practice can easily cut your facility's operating size in half, which increases the number of sick patients in the waiting room and results in frustrated patients leaving without treatment.

Idea: Obviously, a great facility, adequate staffing of all floors with nurses, getting medical staff to discharge patients early in the day and other measures are the most important components of in-patient capacity. In addition to these, consider placing one hall bed on each inpatient floor of your hospital rather than keeping them all in the ED (after checking your state regulations). After all, once a patient qualifies for admission he or she requires an inpatient setting, not the intensity of the ED. Floor nurses may resist, but "spreading the pain" works. Also, while expensive to operate, don't underestimate the value of a hospital medicine program if you don't already have one. Having a physician on hand at all times to admit and discharge patients can do wonders for your daily census.

5. We Love You, But...
In 1687, when Sir Isaac Newton declared that the "innate force of matter is a power of resisting," he may as well have been talking about making changes in the ED. Many peoples' reaction to change is innate, powerful resistance. More often than not, this is not sour pessimism; it is a learned response developed over years of frustration and discouragement with seemingly insurmountable obstacles. Making changes in your ED is likely to stimulate this reaction.

Idea: Encourage those in positions of power to act as forces for change. Newton tells us that, absent the power of an outside force, things continue in their present state. Obtaining buy-in from those in positions of power from C-suite leadership to ED nurse and physician leadership is the best way to get that force moving. Then, when good changes (even minor ones) occur, point them out so everyone can see that the seemingly immovable object is now in motion. Finally, identify those agents who refuse to budge and give them the option of finding another place to bunker down. Changing management requires desire, aptitude and training-choose leaders well on this front and foster their growth.

The task of improving ED throughput is not simple, but it is critical for the health of your patients and your hospital. Develop a plan involving key stakeholders, and gather the tools you need to recognize small victories. Above all, address the challenge with the hope that it can be overcome. Hope alone is not a strategy, but it is a powerful agent for change.


Lynn Massingale, MD, FACEP, is chief executive officer and co-founder of TeamHealth, the nation's leading provider of hospital-based clinical outsourcing and administrative services. Founded in 1979, TeamHealth is affiliated with over 5,900 healthcare professionals who provide emergency medicine, radiology, hospital medicine, urgent care and pediatric staffing and management services to over 560 civilian and military hospitals, surgical centers and clinics in 45 states.

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