The New ED: Keep Patients Out (but Happy)

“I recently told my boss, Peter Slaven [MD, president of Massachusetts General Hospital], that in five to 10 years, ‘The ED will be the most important department in this entire hospital,’ and he laughed,” recalls Alasdair K. Conn, MD, chief of emergency services at the 900-licensed-bed hospital in Boston. 

But, Conn explains, “Here’s how it’s going to work. We’re moving into bundled payments and all these sorts of schemes to try to contain costs. So we’ll need to look very closely at how we use the most expensive resource in the healthcare system, the staffed inpatient bed.”

Massachusetts, of course, learned many of these lessons first as it grappled with a 9% increase in ED visits between FY2004 and FY2008, and a 13% increase in avoidable visits, subsequent to that state’s 2007 legislation that required most residents have health coverage. Armed with an insurance card, many patients felt entitled to healthcare for the first time, but found a shortage of primary care providers and intolerable appointment wait times. So they went to the ED, creating what Conn acknowledges has become “a bit of a crisis.”

“We realize that we have to turn around some of these patients and either treat them in the community or in alternative sites, or alternative healthcare systems,” which health systems everywhere will have to build, he says.

Court challenges to the individual mandate portion of the Patient Protection and Affordable Care Act notwithstanding, emergency room planners are envisioning this expansion on a national scale. 

“Very few people in the ED think that volumes will not increase, and most think it will be about 10% across the board,” says Jody Crane, MD, an emergency medicine physician at the 437-licensed-bed Mary Washington Hospital in Fredericksburg, VA, and an ED faculty member at the Institute for Healthcare Improvement.

Hospital emergency officials say they’re rethinking every aspect of emergency care, from the credential levels required of those who provide it to the architecture and comfort of the places where it occurs. They’re looking at metrics such as door to triage, door to doctor, registration time, door to scan, and door to release.

One thing Crane says will happen first, especially with larger emergency departments dealing with over 100,000 visits a year, will be the creation of on-site clinics or urgent care episode centers. “Patients will be screened at the front door of the emergency department, and if they don’t look sick, they’ll go down the hall, so nonsick patients don’t interfere with the flow of the really sick.” That’s already happening at a number of hospitals that have expanded.

Team triage is another strategy that’s making ED flow move much faster, Conn and several other ED efficiency specialists say. At MGH, a 5.6-hour average length of ED stay has been reduced to 3.5 hours simply by having a physician evaluate the patient first, along with a midlevel provider such as a triage nurse, eliminating the redundancy and waste of time when asking the patient the same thing at separate times.

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