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Why Is The ED Such A Pain?

Molly Rowe, for HealthLeaders magazine, January 15, 2008
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The emergency department has a culture all its own with a unique set of challenges to match. It's also your hospital's window to the community. So you'd better make it work.

Most hospital leaders pray that their emergency department's shortcomings don't show up in the daily news. Not Chuck Stokes, president of North Mississippi Medical Center in Tupelo. Before NMMC-Tupelo undertook an overhaul of its troubled ED, Stokes and his board chair did what many hospital leaders would consider unthinkable: They bought a full page ad in the local Sunday paper that detailed their ED's challenges.

"The ad said, 'We realize that we've got problems in our ED; here's what we're going to do to fix them, to improve our turnaround times, our community relationship. We'll give you a follow-up in six months,'" recalls Stokes. Six months later, as promised, another full page ad described the 580-staffed-bed hospital's ED improvements--and what NMMC-Tupelo had planned for the future.

Such are the drastic measures executives are sometimes forced to take to salvage the most unique--and often intractable--part of their hospital. For many organizations, the emergency department is an island with an ocean of lost profit and inefficiency separating it from the rest of the hospital. Even the most advanced facilities can struggle to get the ED on board with hospitalwide patient safety programs, patient flow efforts and technological advances like electronic medical record systems. When a hospital needs to pilot test a new initiative, the ED is often ignored--and when it comes to actual implementation, the ED is usually the last place to adopt new processes. In fact, hospitals spend thousands of hours and dollars to implement processes that work everywhere except the ED. What's more, the adrenalized environment of the ED makes managing the department an even greater challenge.

How can senior leadership integrate the ED's unusual culture into the broader goals of the hospital? Or, in simpler terms: What makes the ED so difficult, and what can hospitals do to fix it?

A part of the whole

While hospitals might be inclined to treat the ED as a problem child, the American College of Emergency Physicians estimates that in most settings, 60 percent of all hospital admissions come through the ED--which means you'd better get that problem child in line. "The ED is the front door to your hospital and the window to the community. You can't afford not to have it work right. If leaders continue to see the ED as a financial drain on their hospital, they're not seeing the bigger picture," Stokes maintains.

The ED is often a symptom for how processes work--or don't work--in other parts of the hospital. Many hospitals find that changes to process outside of the ED drastically improve processes inside the ED. "The emergency department is very dependent on the lab, X-ray, floor nursing, ICU, pharmacy . If those things aren't working well, I don't care how big you build it, it won't work better," says former ED practice manager and ED director Lynn Massingale, MD, chief executive officer and co-founder of TeamHealth, a Knoxville, TN-based clinical outsourcing firm.

When Wanda Della-Calce joined NMMC-Tupelo as director of emergency services two years ago, she spent two months in scrubs, sitting in the ED lobby and at the nurses' station, to identify bottlenecks and evaluate the use of resources. As the 22-year ED veteran suspected, many of the ED's hold-ups weren't really in the ED at all. For example, in the lab, tests from the ED were thrown into the same pile as tests from the rest of the hospital, so the ED was clogged with visitors just awaiting the results of basic labs. And when ED visitors were slated for admission, they remained in the ED until the admission process was complete, so the ED was filled with patients who no longer belonged in the ED.

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