Overcrowded emergency departments (EDs) with excruciatingly long wait times have become commonplace in our health system today. That is because EDs have taken on a much more expansive role in the provision of care than in years past.
“In today’s health care environment, the emergency department has really become the safety net of most health systems,” said Martin Lucenti, MD, PhD, senior vice president, product strategy and innovation at Vizient. He said today’s EDs are more like acute diagnostic centers, which have to serve high-, medium- and low-acuity patients.
But offering such a wide array of services for such a broad spectrum of conditions can be detrimental if ED leaders aren’t prepared. They need to ensure they’ve allocated their resources to treat these patients properly, or they risk facing a crowded, backed-up ED with high numbers of patients leaving without being seen.
A recent Vizient collaborative – a follow up to last year’s collaborative that focused on ED throughput – gave participants an opportunity to dig into the scope of services provided within their own individual EDs. They were able to see how that affected throughput and how to more effectively manage the change in the scope of services they provided.
How EDs differ
Every ED plays a slightly different role within its health system, said Lucenti, so each organization in the collaborative had its own unique issues. But the group did find some common themes.
“What you’re seeing around the country is, more and more, the ED is where you can pull together all the diagnostics to get answers,” he said. “Whether you’re acutely ill or less so, but still need a significant work up to identify the issue, that work up may now be happening in the ED.”
The ED often has resources available – diagnostic tests, like urinalysis, CAT scans and MRIs – to understand a patient’s condition. That means rather than a patient spending 24 to 36 hours visiting multiple sites for testing, with EDs beginning to own that entire window of care, a patient now might spend that time in the ED instead.
Getting less ebb and more flow
To begin to tackle the issue of overcrowding and backlog in the ED, fundamental steps like assessing your scope of care, to determine what services you provide, when during the day you provide those services, and operational factors that may inhibit your ability to do so efficiently, must be in your game plan.
“The single most critical factor in analyzing your ED’s scope of care is the arrival rate versus the service rate,” said Bradley Schultz, principal, advisory solutions, at Vizient. “Patients arrive in the ED at a certain rate per hour, and the ED can provide service to a certain number of patients per hour. When the arrival rate exceeds the service rate, patients wait. When service rate exceeds arrival rate, the ED works through its patient backlog.”
Schultz, who has worked closely with numerous Vizient members on these type of performance improvement projects, pointed out that patients rarely arrive at the average expected number in any given hour. But ED administrators often still plan for the average, which is really just a midpoint.
“That’s the number one problem that we find in most hospitals – they designed around the average. They don’t take into account the variability.”
Secondly, in order to treat a patient, you have to have a nurse, a doctor and a bed,” Schultz said. The availability of each of those resources affects the service rate and patient flow – which, according to Schultz, also includes flow of information and service.
Schultz and Lucenti work together to find operational factors that might inhibit that flow. For example, doctors typically treat patients in the ED from sickest to least sick. But that means the least sick patients might wait hours for treatment. Lucenti suggests that EDs could operate more efficiently by creating queuing systems with separate tracks for those patients, almost the way grocery stores have 10-items-or-less lanes, he said.
Other factors may inhibit flow but aren’t necessarily negative. For example, if the hospital has decided to keep admitted patients in the ED until inpatient beds are available, “it gums up your ED, but it also provides for safer patient care,” said Schultz. “We just have to work with the reality of their systems.”
The work mix of the people who deliver the care can also inhibit flow. A physician may say that necessary diagnostic tests are frequently delayed. While that may be true in some cases, in others, it may be a time management issue on the part of the provider.
“What we try to do is separate all the signals from all the noise,” said Schultz. “The biggest thing you’ve got to do with hospital leaders is get them out of the world of talking about it and into the world of doing something about it.”
But whereas companies like McDonald’s and Walmart are used to studying capacity-demand issues in great detail, “those aren’t really sciences that EDs and health systems have fully embraced,” said Lucenti. He estimates that only about half of the ED leaders he speaks to can tell him their busiest hour of the day for patient arrivals, and far fewer can say what the expected arrival number is during that hour.
“Understanding some of those operations and management sciences as they apply to hospital operations is relatively new,” Lucenti said. “It’s not a new concept. It’s a new concept to health care.”
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Vizient, Inc., the largest member-driven health care performance improvement company in the country, provides innovative solutions, expertise and opportunities to improve care and lower costs.