Why Is The ED Such A Pain?

Molly Rowe, for HealthLeaders magazine , January 15, 2008
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"When I got here it was a like a war zone--a hostile environment. The lobby was full of patients; they were sitting everywhere. The nurses stayed behind glass of central nursing station. By the time people got in rooms, they were mad and yelling at nurses," says Della-Calce, who now serves as service line administrator for emergency services.

Della-Calce implemented changes to fix these and other hospitalwide processes. ED tests were flagged high priority for the lab so they were no longer lost in a sea of other tests. The hospital developed a rapid-admit unit to quickly move patients from the ED when they need to be admitted. Rather than sit around the ED awaiting admission (sometimes overnight), patients now move to the rapid-admit unit for preadmission procedures like IV insertion or medical history.

Perhaps the most important change, however, is that everyone at NMMC-Tupelo recognizes and understands that the ED's involvement in hospitalwide initiatives is required.

"ED leadership needs to be an active participant in other committees. They have to attend medical executive committee meetings. They can't see themselves in isolation as a standalone department of the hospital . because they are a service department to the rest of the hospital staff," Stokes says.

Big doesn't always mean better

UMass Memorial Medical Center opened the doors of its multimillion dollar emergency department in Worcester, MA, in February 2006. One of two EDs in the three-hospital system, the much-touted department attracted a flood of patients. Within 48 hours of opening, staff members were lining up hall beds for overflow patients, and within two weeks, the ED was back to being almost permanently overcrowded.

Located outside Boston, UMass Memorial's two EDs see upwards of 130,000 admissions a year. But even smaller, less busy EDs struggle with long waits, high elopement and unhappy patients. Like UMass, many hospitals try to remedy such problems by undertaking expensive ED renovations, only to discover that sheer size doesn't necessarily solve anything.

Turning around an inefficient ED doesn't require a multimillion-dollar overhaul--but it may require some improvements to the existing facility. In NMMC-Tupelo's case, it meant making basic changes to the lobby area to facilitate good customer service. The hospital constructed a children's play area, installed a computer with Internet service and built a refreshment area.

"We took registration out of the front side and put it on the back side. We closed all the registration booths up front, did some remodeling, and turned that into family waiting rooms so if there was a critical patient, these families could wait outside of the general waiting room," Della-Calce says.

Once a patient is assigned a patient care room, registration, labs and treatment all occur in that room. Every ED room includes a flat-screen television, and the hospital installed computers in every room to better facilitate use of the EMR. "The perception from the patients was that the nurses stayed behind the desk, but the reality of that was that they had to go behind the desk just to chart on the medical record," asserts Della-Calce. With the new set-up, the nurse interviews the patient in his room and enters the information at bedside rather than going back to the nursing desk. The registration clerk uses the same computer system.

Culture shock

Perhaps more than any other department in the hospital, the emergency department is defined by its culture. No other area of the hospital is as action-oriented, and no other area has so little control over its pace. If five patients or 50 patients present to the ED on any given day, the ED staff must adjust to handle patient flow. ED physicians and nurses must make a lot of decisions very fast. In a busy ED, there's often little time to build consensus or solicit opinions--which makes strong staffing relationships critical. "The physician leader and nurse manager must have a healthy respect for each other. If they don't, something is wrong, and it's a prescription for disaster in the emergency department," maintains Massingale.

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