Parkland Health and Hospital System in Dallas, struggling to conform to a corrective action plan to correct "serious deficiencies" documented by the centers for Medicare & Medicaid Services, has been making progress in improving its emergency department. But it is still falling short in making improvements associated with its emergency department.
Fixing an ED is a slow process. A few months ago, Thomas Royer, MD, interim CEO of Parkland, told me how the hospital ED volume spilled over the night before we spoke. "We had 200 people waiting in the Emergency Department to be seen. We had to go on total diversion because we had no beds in the hospital," Royer said.
Problems of the ED linger, of course, not only at Parkland, but elsewhere in the nation. This is reflected in the May HealthLeaders Media Intelligence Report, "Volume, Flow and Safety Issues in the ED." "The ED can get backed up with patients needing inpatient beds, leaving us working out of three or four rooms where we have a 25-bed capacity and 10 stretchers in the halls," a director of emergency service services says.
Intelligence Report advisor, Gary Tiller, CEO of Ninnescah Valley Health System, which operates the 25-staffed bed Kingman Community Hospital, 25 miles west of Wichita, KA is pessimistic. "We are going to get overrun. I don’t know if we are going to be able to handle it, truth be known. It’s going to be a mess, honest to God," Tiller says, predicting the consequences when more uninsured use the ED.
Some may consider Tiller’s comments hyperbolic. Yet his words convey the depth of the daily grind, echoed by Parkland’s Royer and the unnamed director of emergency services in the Intelligence Report. Their words underscore the obstacles faced by this country’s EDs. And the report shows that among the greatest challenges in the ED is improving patient flow.
In the survey, nearly half of the respondents— 46%—described their EDs as overcrowded, and of that group, 93% expressed concern about patient safety. They also express concern about financial implications. About 80% are expecting their ED revenue margins to worsen as a result of healthcare reform, and 78% say their reimbursement will worsen.
Amid those glum prognostications, many health systems are moving forward to make the ED better. Indeed, an overwhelming share of hospital leaders— 95%—say they have current or ongoing efforts to improve throughput in the ED.
And this is where physicians can step up their involvement to make the ED better, even if they work nowhere near it, because it is the gateway to the hospital.
A collaborative effort to improve the ED involving physicians and administration is occurring at Providence Hospital in Washington D.C., where hospital leaders have laid out dozens of plans with hopes of invigorating the inner city hospital’s ED. Some proposed improvements are similar to those enacted by other health systems, as reflected by those who answered the survey.
Among the most effective techniques cited for increasing ED efficiency:
- Fast-track area for less severe illnesses or injuries—65%
- A triage medical evaluation process—56%
- Coordination with inpatient floor nurses—55%
In some cases, Providence is trying to go further. "The ED affects all aspects of the hospital," says Kim Bullock, MD, an emergency department physician at Providence Hospital who has participated in meetings with other doctors and hospital officials to improve the ED. Bullock is also director of community health and assistant director of service learning in the department of family medicine at nearby Georgetown University Medical Center.
"All (hospital) services were eventually included in the discussions. And it involved everyone from the CEO to housekeeping, from admittance staff to environmental services. Everyone has a stake in the game, in order to get sustained solutions."
Specifically, the meetings focused on "procedural improvement and interdepartmental cooperation in improving ED efficiency, patient transfers, and ancillary services support," Bullock adds. They talked about doing a better job communicating at the bedside when there is an admission to an available room; they talked about coordinating plans with housekeeping to move things along quicker. They talked about the importance of improving physician and nurse communication in the ED. All told, Bullock says the discussion focused on 64 planning points.
To deal with patient safety and other concerns, Providence appointed a "throughput task force," which included physicians and administrators, to evaluate methods to improve the ED, she says. While there is often talk in healthcare about "physician champions," Providence selected one strictly for the ED.
Hospitals also must work "externally" to improve the EDs, she says. "Cross dialogue between hospitals would advance collaboration and problem solving in these and other areas; however this has not been explored because most institutions work in silos."
"As hospital leaders evaluate [a hospital’s] throughput agenda, they must not only evaluate crisis situations, but the continuum of care that begins in the ED," Bullock adds.
She is hopeful in the process that Providence officials have initiated. "The fact that a community hospital has taken such an interest in improving the ED services means that upper level administration ‘gets it’ in terms of the importance of the service delivery in the ED. There is a bottom fiscal line here, which many hospitals recognize but still do not prioritize in the way that they should," Bullock says.
Physician involvement is crucial to transform any ED, but the responsibility rests not only with those who work there, Bullock emphasizes. Surgeons, specialists and primary care physicians assigned elsewhere in a hospital must play a role. ED delays, patient satisfaction, and performance measures are all tied together,
"Attitudes must change generally. That's not just an ED problem mentality, but a hospital problem," Bullock adds. "And unless everyone becomes involved, everyone loses."
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
