State of Emergency

But is the expensive imaging equipment worth the cost? That depends on how you look at the ROI, explains Gross. "ERs are oftentimes the front door and first experience a patient can have with an organization. To create patient loyalty, it's a good investment to fully meet patients' needs because we'll have repeat customers. Also, to the extent that one can become more efficient, with better throughput you can see more patients, as well."

Key No. 2: Keep docs, nurses happy
Not every hospital has such a rosy outlook on the ED, however, and most don't have the resources to expand or modify their departments right now. The ED can be a financial drain for hospitals in areas with large populations of uninsured or patients on Medicaid or Medicare, particularly when a significant portion of patients are presenting to the ED for routine or nonemergent care.

In these situations, hospitals often focus less on getting patients through the ER and more on keeping them out of it. Some rely on deferral of care, a strategy where providers perform the minimum assessment required under EMTALA and then ask patients about their ability to pay; if they can't they are referred to a nearby clinic or advised to seek care elsewhere.

While care deferral can make financial sense on the surface for some hospitals, strategic decisions can't be made without considering the repercussions with the physician and nursing staffs. Emergency physicians often consider it a moral obligation to treat all comers and prefer increasing throughput to restricting care in the ED.

"If a hospital is having trouble recruiting physicians, it needs to look at its environment," says Sandra Schneider, vice president of the American College of Emergency Physicians (ACEP) and professor of emergency medicine at the University of Rochester (NY) Medical Center.

Nurses, too, place a lot of importance on the ED environment and culture. A crowded ED not only increases workloads for physicians and nurses, but it contributes to burnout and a chaotic culture that can push providers to leave, says Schneider.

Retention is so important because of severe shortages of both emergency physicians and nurses.

"A crowded ED that boards patients for a long period of time is going to have an extremely hard time keeping nursing staff and a hard time keeping physician staff," says Schneider. "Since a large number of our hospitals are boarding patients, they need to understand that in doing so they've created a major disincentive for working in that institution."

It's not just that there aren't enough nurses—there aren't enough being trained, either. Tomball Regional Medical Center has had some success partnering with the local community to raise a bond fund to expand the nursing school, says White. But for most hospitals, increasing training isn't an option, so retaining existing staff and creating an appealing environment to recruit new nurses and physicians is the only real option.

Key No. 3: Cut down on boarding
Contrary to public perceptions, though, EDs aren't crowded because of the volume of patients coming in. Many EDs get backed up because of a lack of inpatient beds or operating rooms. Physicians have nowhere to send patients, so they end up lingering in the ED and clogging it up for the patients behind them. A 2004 study found that hospitals lose nearly $1.74 million each year in potential revenue because ED beds are blocked by already-admitted patients.

While improving front-door issues related to ED operations is important, hospitals also need to consider back-door improvements, which involve looking outside the ED at hospital operations that can slow the admission of patients and ultimately bottleneck the ED.