For a long time, waiting has been almost synonymous with emergency departments in American hospitals.
But hospitals are streamlining their emergency departments to reduce waiting times as EDs continue to be swamped with increasing numbers of patients.
In 2009, Americans averaged 4 hours and 7 minutes in ED waiting rooms before being seen. And more people are expected to be crowding into EDs over the next several years. Emergency visits may increase as much as 5% to 10% over the next several years in the wake of the healthcare reform law.
Waiting in the ED often has a negative impact on patients' attitudes, with many simply deciding to leave the hospital, despite needing care, and despite the likely consequence of poorer health outcomes. The unfolding scenario has a potentially detrimental impact not only on the patients themselves, but also on overall hospital business.
To meet demands of patients, hospitals are working diligently to ramp up services and decrease wait times by restructuring waiting areas, placing nurses and physicians in entrance areas for "fast track" services, evaluating serious and nonserious conditions among patients in the ED, or evaluating specialized conditions, such as asthma, to improve patient flow.
Such innovations not only have improved patient care, but they inevitably feed hospital revenue because patient care usually begins with the ED, hospital officials say. There were nearly 117 million patient visits to the nation's emergency rooms in 2007, a 23% increase over a decade earlier, or 39.4 visits per 100 persons, according to the National Health Statistics Reports.
By making improvements to the ED, "there has been a positive impact even though the emergency department is not a money maker, per se," says Valerie Norton, MD, medical director for the ED at Scripps Mercy Hospital in San Diego. "You can't look at it in isolation as a separate silo. It's a feeder of inpatients for the hospital. Urban EDs are admitting 20% of the patients who come through the ED. It's very good revenue for the hospital and we are able to increase the volume."
Hospitals also are under increasing pressure to improve EDs, not only because of the need to serve additional patients but also because of the competitive nature of the services, says John Federspiel, MBA, president and CEO of the 128-staffed-bed Hudson Valley Hospital Center in Cortland Manor, NY.
When HVHC initiated a program in 2005 to speed up review of patients in the ED waiting area, the average time for patients to be evaluated by a medical practitioner dropped by 47%—just one month after the initiative began. Since then, the hospital has gradually reduced waiting times. Federspiel says he attributes an increase of patient volume in the hospital—about 20%—to improvements in the ED.
Having a speeded-up ED process is something "we take advantage of," he says. "We have a half-hour distance from our competitors. People have a choice where to go for their ED treatment. We're doing this because people are voting with their feet."
Success Key No. 1: Decreasing walkout rates
One of the major problems for emergency departments has been dealing with the "walkout rates"?potential patients who grew frustrated waiting in the ED and decide to go home or to another facility. The longer the patient waits, the more likely he or she will leave without treatment, resulting in potential problems for the patient as well as lost income for the hospital.
The Scripps Mercy Hospital, a 700-licensed-bed facility, focused making ED improvements that included targeting the walkout rates. By effectively separating patient groups, by illness, for example, the hospital has reduced the number of walkout rates. In June 2009, the patients who left without treatment were 253; that figure was reduced a year later to 11 in June 2010.
"People were sitting in the waiting room and got fed up," says Norton. At one point, 5% of patients were leaving the ED between July 1, 2009, and February 23, 2010; the hospital has decreased that total to 0.4% between February 23, 2010, and June 30, 2010.
The result has been more patient volume in the hospital "because we've been able to get more patients in, and ambulances that used to be diverted away from the hospital are no longer diverted," she says. "The word has gotten out to the community, and more people are showing up. And that is a savings, too, with the ambulances no longer being diverted."
At the Scripps Mercy ED, patients seeking treatment are immediately assessed by a nurse who determines whether the patient requires a bed or recliner, depending on the severity of the case. When a bed or recliner is available, the patient is taken back to the designated area immediately.
"The biggest challenge was getting rid of the up-front wait," she adds. "In the old traditional way, you'd be in bed for two hours. Now we are taking people out of the beds and have them in chairs. We are turning over the beds rapidly for people who really need them."
Such movement is important, she says, because "really sick patients account for only 30% of the volume" in emergency departments. "Patients are served very poorly by having to wait in waiting rooms."
Success Key No. 2: The asthma lounge
After studies in Oakland, CA, that showed more than the usual number of cases of asthma, Alameda County Medical Center, a 236-licensed-bed facility, established a specialized unit for asthma patients that hospital officials say has resulted in improved overall outcomes for asthma sufferers as well as reduced wait times for other patients in the ED.
With creation of the asthma lounge, the average wait time for ED patients with asthma attacks fell from 128 minutes in 2006 before the lounge opened, to just 4 minutes, according to the hospital.
"Before we had such a backlog of patients who were in the emergency department, often because of asthma patients," says Rosemery Williams, manager of pulmonary services for the hospital. Asthma patients "would come in with shortness of breath or chronic lung problems. They often didn't have a primary care doctor, and would use the emergency department as a drop-in clinic" she says.
The new clinic "has significantly reduced wait times and has enabled asthma patients to be treated before a significant emergency," says Williams.
With its ED triage system, the hospital quickly treats asthma patients and provides immediate assistance to those experiencing attacks. The patients needing assistance go to the asthma lounge, which is located within the ED and includes two beds and two lounge chairs and is staffed 24 hours a day. Nurses and respiratory therapists, often using nebulizers, work to relieve the asthma attacks.
An education component is considered important to the program because patients need to "recognize the symptoms of asthma. Some patients who have asthma don't realize they need urgent care," says Brandy Burrows, ACMC's director of respiratory care services.
Under the education plan, patients learn the triggers of an attack and when there is a need to start treatment, and then they begin to establish a sensible relationship with a primary care physician. It improves and speeds up the process, she says. The hospital expects to expand its coverage in the asthma lounge. "This has been a safety net, and now with the recession more people are coming in, and it's more important than ever," Burrows says.
Success Key No.3: Pharmacists in ED
By having pharmacists in the ED to review high-risk medications prepared for patients, Sarasota (FL) Memorial Hospital has achieved better patient outcomes and reaped substantial savings in pharmaceutical costs, according to Deborah J. Larison, PharmD, CPh, clinical pharmacy specialist
and toxicology/emergency medicine director for the 806-licensed-bed hospital system.
"Most EDs across the nation don't have pharmacists. They have a central pharmacy that processes orders, and have limited hours," says Larison. "By having the ED pharmacy, we head off potential problems before they occur. We can clarify patient allergies for physicians and determine cross-sensitivity to avoid adverse reactions."
Pharmacists are assigned around-the-clock to the Sarasota Memorial Hospital emergency department. "From a business perspective, it enhances the patient care and there are overall decreased costs," Larison says. Pharmacists have reviewed drug supplies in the hospital and there have been reduced costs in budgets when it was determined some pharmaceuticals were not needed as much as others, she says.
"We actually saved money by significantly decreasing the amount of drugs we don't use," Larison says. "If we can intervene at the outset, that is the best choice for better outcomes."
Although Sarasota officials are still compiling revenue figures on pharmacists assigned for the ED, studies conducted for the American Society of Health-System Pharmacists, show significant savings for hospitals, Larison says. In one of the largest studies, in 2003, pharmacists participated over a four-month period in the care of 1,042 patients triaged in the ED, and 2,150 pharmacist interventions were documented—which included recommendations for drug adjustment, alternative drug therapy, drug compatibility, and other issues. The overall savings amounted to about $1 million, according to the study.
The ASHSP has recommended that every pharmacy department provide the ED with pharmacy services to ensure safe and effective patient care. Only a small percentage of hospitals now have pharmacists in the ED, but the numbers are growing, according to Larison.
The idea is "to assist the physicians and nurses and enhance the care of the patients," she says.
Success Key No. 4: Videos for emergencies
Pediatric emergency and critical care physicians at UC Davis Children's Hospital use videoconferencing with patients and physicians and 10 EDs in rural and underserved areas of Northern California. The program has been found to improve diagnostic and treatment processes, while likely resulting in cost savings, better quality of patient care, and increased family satisfaction, says James Marcin, MD, director of pediatric telemedicine for the Center for Health and Technology at the 110-staffed-bed UC Davis Children's Hospital.
The enhanced video technology allows UC Davis to offer expertise to rural healthcare facilities that typically have less access to pediatric subspecialties. Rural EDs may lack the resources to adequately assess and optimally treat acutely ill and injured children, Marcin says.
Using high-speed data linked to video units at the UC Davis Medical Center, outlying California hospitals and clinics, physicians, and patients can have a live interactive connection with a UC Davis specialist by simply dialing the specialist and seeing him or her on video.
The program also provides these remote EDs with standardized triage protocol, laminated reference cards, and periodic pediatric critical care training in an effort to increase physician knowledge and improve consistency and quality of care.
Marcin says the program is especially important for rural areas with geographical barriers, such as those in or near the northern Sierra Mountains. Specialists can't simply fly into certain areas quickly to provide care, but they are able to connect with the video unit, he says.
"Often, it is very difficult to drive a patient many miles to see a specialist," Marcin says. "Telemedicine is a key to access a specialist who can assist in a diagnosis and offer the best possible treatment plan for a patient."
Rural EDs are less likely to have access to pediatricians, pediatric subspecialties, and ancillary services. An Institute of Medicine study found that children account for 27% of all ED visits, but only 6% of EDs in the United States have the necessary supplies for pediatric emergencies, Marcin says.
The hospital also has a "family-link" program that helps families stay connected when a child is hospitalized. Using a special camera and phone unit, the link lets parents see and talk with children in a hospital.
Besides handling emergencies, the UC physicians provide specialty and intensive care consultations. The result has been higher patient satisfaction scores, Marcin says. UC Davis is evaluating patient satisfaction, but records show that a majority of families consider telemedicine extremely important, he says.
Overall, telemedicine can be a solution to the projected physician shortage problems, Marcin says.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
