Another important part of the new ED personality will be a focus on patient experience scores because, under healthcare reform, one-third of the 1% withhold of a hospital’s inpatient Medicare reimbursement will be based on patients’ survey responses. Patients will judge their hospital on how long they had to wait in the ED, and the longer they had to wait, the more unhappy they will be.
“The old attitude in the ED, ‘We’re here to save your ass, not kiss it—those days are gone,” says Jay Kaplan, MD, FACEP, an emergency physician at 235-licensed-bed Marin General Hospital of Greenbrae, CA, and a member of the ACEP board of directors. Reducing wait times is important, he says, but equally important may be communication, to let patients know how long the process will take.
But patient experience scores are easily affected by how long a patient had to wait, says Conn. At MGH, they’ve figured out “by and large, if the wait is less than four hours, they’re okay. But if the ED wait is longer than four hours—the workup in the ED or the wait for an inpatient bed—the satisfaction scores drop off pretty fast.”
Hospital EDs will be expected to have wireless Internet access, as well as greeters who walk through the ED and make contact with patients and family members in a reception area. “Don’t call it a waiting room anymore,” says Kaplan, who also serves as director of service and operational excellence for CEP America, Emergency Physician Partners, a physician contract group that staffs 80 EDs around the United States.
Some hospitals are trying to measure their flow times with patient-tracking systems, such as one that involves a wireless electronic bracelet, which can also help ED teams find the patient who may have wandered off.
Many hospitals are not just remodeling their emergency departments and giving them more space with larger rooms that are more patient-centered, but they are also making them a feature presentation of the entire building.
“There’s a fundamental change to what’s happening with the ED,” says architect Frank Zilm of Frank Zilm & Associates, a Kansas City, MO-based firm that specializes in healthcare facilities. “Think back 20 years ago; the emergency department was traditionally located at the back of a hospital so the ambulances wouldn’t interfere with the lobby. Now they’re the front door of the hospital, and that’s going to continue with healthcare reform.”
Hospital chiefs, too, are realizing that for marketing, the appearance of the ED should appeal to women, who live on average nearly a decade longer than men and are greater users of hospital care. “Ten times the number of women will be seen in the ED as will deliver in the hospital, and that should be a critical component in strategy,” Zilm says. “Unfortunately, most healthcare facilities have lagged in an appreciation of that role. EDs have a perception of being overcrowded and a loss leader.”
EDs are being redesigned with chairs instead of beds for patients who are ambulatory, with areas for patients who are waiting for results, and with special areas for extended observation units, which will be dedicated and larger. Exam rooms have two headwalls and two power columns so they can hold two patients if necessary.
Exam rooms are likely to be larger, and individualized rather than in an open bay setting. “Now, when you look at the demographics, almost one-third of patients who come in to the ED will be over 65 and, typically, they will come in with someone to support them, in many cases the daughter,” Zilm says.
EDs are being designed with toilets to mitigate trips down the hall and whiteboards to encourage patients to write notes. And for waiting family members there are computer terminals, play areas, and coffee shops, “options that the family can feel as comfortable as possible with the stress in the ED,” Zilm says.
Crane sums up that in his experience, “there’s an incredible amount of inefficiency built into the ED system today. And almost everyone I walk into has a number of operational flaws, which, if they went to work on grassroots improvement to improve flow, any ED in the country could improve flow by 25%.
“That translates into a length of stay of four hours that is reduced to three, or the same as adding 25% more ED beds. EDs aren’t thinking that way now, but they’ll be forced to think that way,” Crane says.
Many of those improvements, he says, are in the front end in EDs without significant boarding issues. “Getting the doctor and patient together right away can shave an hour off the patient’s visit and can keep things moving,” Crane says.