A Necessity, Not an Option: Rethinking ED Systems

The December 4, 2008, edition of QualityLeaders addressed the need for a third option to ease emergency department overcrowding instead of resorting to boarding patients in EDs or placing them in inpatient hallways.

Emergency departments nationwide deserve gold stars for their creativity in mitigating the effects of overcrowding by making processes more efficient through quick registration, provider in triage, bedside registration, standing orders, and the use of fast track and sub-waiting areas, to name a few. For some, there is simply no more bandwidth to utilize, no other efficiencies to be gained outside of changes intended to reduce bottlenecking for getting admitted patients to inpatient beds quickly.

Patient satisfaction surveys have shown that patients seeking care in the emergency department primarily want two things: good medical care and reasonable wait times. Boarding of inpatients in the ED inhibits the ability of ED staff to achieve both of these goals.

While growing in popularity, retail health clinics do not appear to be part of the answer, as surveys conducted by MinuteClinic have shown the bulk of patients utilizing such centers would have otherwise sought care at a physician office or urgent care center (95%), not an emergency department (only 5% of respondents).

Many point to urgent care centers or freestanding emergency departments as a model of the future, because they are not equipped to provide inpatient care and must transfer the patients to a hospital setting and are therefore immune to the ED boarding problem. But arranging transportation for a hospital admission effectively moves the admission bottleneck right back to the hospital and likely results in the patient waiting in the hospital ED, effectively doing little to solve the boarding problem but allowing some time to identify a bed. So regardless of the proliferation of urgent care centers, hospitals will still need to address the complex "admission process."

The third option that will solve this problem is to re-engineer the traditional systems that still dominate the majority of hospitals today so that there is minimal waiting for care in the ED and transportation to a clean available bed on an inpatient unit. This is a formidable challenge, as it requires the following:

• Simplify the hospital admission process. The process to admit an emergency department patient to an inpatient bed is a complex one. Once the ED physician has made a decision to admit the patient, it can often be a challenge to get some hospital services to accept a patient, let alone provide a timely consultation to evaluate the patient. This can take hours. Once this hurdle has been cleared, then there's the issue of completing the required electronic and/or paper forms, creation of an inpatient chart, and identification of an available bed. If a patient is fortunate enough to have a bed identified, the chances that it is clean, the inpatient floor nurse is available to accept the report, and transportation is available to whisk the patient to his or her inpatient bed are slim to none. Even when the hospital is not at full census, the multitude of steps and subprocesses involved requires significant coordination among the ED, inpatient floor, housekeeping, transportation, patient access, and the admitting physician. Phone calls are not promptly returned. Change of shift personnel require briefing/reporting, which adds further delays. Ultimately, coordinating all the resources involved requires a consensus among stakeholders with competing priorities—hardly a simple task.

Hospital, medical, and nursing staff leadership need to understand the bottlenecks and obstacles inherent in their system that contribute to ED patient boarding. Once identified, firm guidelines need to be put in place to minimize such delays, which will not only improve patient flow in the ED but also help to reduce overall hospital LOS, as well. Some hospitals have adopted a model that decentralizes the key services of transportation and housekeeping and places them under the auspices of a patient logistics area, which can more effectively monitor and control the resources to reduce extensive delays.

• Prioritization of hospital resources for the emergency department. The Centers for Disease Control reported that ED patients comprised roughly 36% of all hospital admissions. Ten years later, in 2006, that percentage had skyrocketed to more than 50%. Some hospitals rely on the ED as a source of 75% of total hospital admissions, yet provide a fewer amount of resources and priorities to the ED, in terms of staffing, space, and equipment. A recent study from the Agency for Healthcare Research and Quality found that across 65 hospitals, the majority felt their emergency departments lacked the sufficient space to deliver quality patient care with a third saying the number of patients regularly exceeds their capacity to provide safe care. Nearly 67% reported that the level of nursing staff was insufficient to effectively care for patients, and 40% felt the same regarding physician staffing.
• Working to reduce non-urgent visits to emergency departments. The Centers for Disease Control reported that in 2006, there were nearly 16 million ED patients who visits were considered to be "non-urgent." While this number did not change from 2005 to 2006, it is clear that there is not enough being done to find appropriate alternative locations for these patients, whose ED occupancy prevents patients with emergent conditions from easily getting timely care. Managed care companies' increase of patient co-pay and co-insurance responsibilities may have dissuaded patients from seeking care in the ED, but this alone is not going to fix the problem. Yet many patients arriving to the emergency department for sore throats and other minor complaints are often the first to complain about slow treatment, perhaps unaware that the physician they are waiting to see is busy resuscitating a patient in the room next door.

There is no short-term or easy fix. And times are getting tougher as the potential for national healthcare reform may lend itself to continued increases in visits to EDs nationally in addition to the growing problems of nursing shortages, lack of on-call coverage, and economic challenges limiting access to capital for hospitals.

Option No. 3 in addressed ED overcrowding is a combination of significant changes by communities, their physicians, and hospitals who must all do their part to alleviate the crisis. But try to tell that to any of the one of the 42,000 patients who are admitted to hospitals from the emergency department in this country each day—I think they would prefer to be held in the ED or on an inpatient floor. Ultimately, the option No. 3 mentioned above is really not an option at all; it is a necessity.