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.
Eric Bachenheimer is director of client solutions for Emergency Medical Associates in Livingston, NJ. He can be reached at Bachenheimere@alpha-apr.com.
How many processes contribute to the quality of care provided in your hospital? How many measures does your organization report to someone in a given year? How many complex requirements must your hospital decipher? Contemplating such migraine-inducing questions can make a hospital leader want to hide in a dark room and lie down for a while. The sheer volume of often conflicting demands placed upon provider organizations—coupled with a deteriorating financial climate—can make the notion of improving care quality seem like an idealistic improbability at best, an impossibility at worst. Is true quality improvement a realistic goal in healthcare's current landscape?
Although I'm sure many executives whose hospitals have been deluged with bad news for months are pretty skeptical right now, the Institute for Healthcare Improvement contends the answer is yes. At the IHI's annual National Forum on Quality Improvement in Health Care last week, President and CEO Donald Berwick, MD, outlined the IHI's "Improvement Map," the organization's latest initiative designed to help hospital leaders sift through myriad regulations, measurements, and demands to hone an essential set of processes and craft an organization-specific plan for quality improvement. "You've got to face away from the chaos and toward the purpose," Berwick told attendees during his keynote address.
An ambitious concept, to be sure. The IHI's 100,000 Lives and 5 Million Lives Campaigns focused specifically on protecting patients from incidents of medical harm; the Improvement Map concentrates on "the entire landscape of outstanding hospital care," according to the summary provided in the conference materials. Berwick said the map will address "a master, overarching agenda of processes."
Sounds good, I suppose—but what kinds of specifics lie beneath the feel-good generalities? There aren't that many to be had at this point. The map does add three new interventions to the 12 from the 100,000 Lives and 5 Million Lives Campaigns:
Adopt the World Health Organization Surgical Safety Checklist.
Link quality and financial management: strategies to engage the chief financial officer and provide value for patients.
Berwick challenged every hospital in the 5 Million Lives Campaign to adopt the WHO Surgical Safety Checklist in at least one operating room within the next 90 days. A "sprint," Berwick called it. The map will also "continue to develop as we learn the shortest routes to the best outcomes. IHI will add interventions over time, clustering them by care setting and content area, and will help hospitals identify where they should focus to maximize impact," according to the summary.
My inclination, I confess, is to be cynical about all of this. Passionate calls to action are common healthcare conference fare. The Improvement Map is still in development, so measuring its potential impact is difficult, to say the least. Yes, the 100,000 Lives and 5 Million Lives Campaigns have made meaningful strides in reducing needless deaths—but a grand objective like covering "the entire landscape of outstanding hospital care" is another matter. And asking every 5 Million Lives hospital to adopt the safety checklist within 90 days? That's more than 4,000 hospitals.
But all of that said, I'm vowing to set aside those skeptical instincts (for now, at least). Because while I'll be watching closely as the program develops, I agree with a deceptively simple premise of the Improvement Map—that you can't implement improvements in a genuinely meaningful way if the fundamental processes intended to create those improvements are flawed. In theory, this is a concept hospital leaders have understood for a long time. In practice, it's a concept that challenges organizations across the country every day. Whether the IHI's newest initiative will be the answer is highly debatable. But merely saying "That will never work" doesn't solve anything.
Jay Moore is managing editor for HealthLeaders magazine. He can be reached at jmoore@healthleadersmedia.com.
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The New Jersey Department of Health and Senior Services has found in its third annual Patient Safety Act report that 72 people died in the state's hospitals last year as a result of preventable errors—30 more than in 2006. Health officials and patient advocates say, however, that the increase appears to be the result of better reporting of these types of incidents, rather than poor care.
The Carle Clinic Association of Urbana, IL, reached an agreement with the state in an anti-trust lawsuit filed by the state's attorney general's office. The Carle Clinic as well as the Christie Clinic of Champaign, IL, are accused of denying primary care to Medicaid patients. The agreement requires Carle to increase its Medicaid patient load by as much as 11,850 over the next three years. Legal action against Christie is still pending.
A project at Pittsburgh-based St. Clair Hospital will increase the square footage of the emergency department from 13,000 to 31,000 and take the number of available treatment rooms from 20 to 46. Among the treatment rooms will be 31 for acute adult care; six for pediatric care; six "fast track" rooms for patients with minor illnesses and injuries, and three behavioral and mental health rooms. The increase in the number of treatment rooms and a revamping of the way the emergency department functions is expected to drastically reduce the amount of time that patients will wait for treatment, said hospital representatives.
The nonprofit Commonwealth Fund has developed a new site, WhyNotTheBest.org, where side-by-side comparisons of 4,500 hospitals nationwide can be found. Hospital-ranking programs and rating systems have proliferated in recent years, but Commonwealth Fund representatives say the new site is meant to fill a gap because existing report cards don't offer hospitals an easy way to compare their performance to each other or offer resources to help them improve. The site offers tools and case studies of high performers, so users can network with people at the best hospitals.