This article appears in the May 2012 issue of HealthLeaders magazine.
Aside from a patient, perhaps no element of a hospital system is as in need of emergency care as the emergency department itself.
Health systems know this and are working to overcome ED bottlenecks by initiating improved throughput systems. They are imposing fast-track, split-care programs to improve patient flow and decrease wait times by caring for patients with lower acuity in one area, freeing up beds for those with more severe illnesses.
It may seem like a dizzying array of models, but hospitals don't have much time in the we-can't-wait-much-longer ED world to improve patient flow and provide safer access to care.
Hospitals are improving coordination among nurses and physicians to ensure that the sickest of patients are seen quickly, working with primary care providers to develop different care for too-frequent ED users, and installing electronic medical record systems to hasten and coordinate care through outpatient centers as well as in the hospital.
Hospitals have been systematically revamping and implementing changes in the wake of a 2007 Institute of Medicine report that called the ED a growing national crisis, citing not only delays of care, but also diversion of ambulances to other hospitals and inadequate capacity to handle a large influx of patients requiring boarding. The IOM described in the report "a widening gap between the quality of emergency care Americans expect and the quality they actually they actually receive."
Moving toward ED improvements is a bumpy journey, but one of slow, steady progress if properly managed, with health systems finding direct throughput gains not by singular, but collective changes, hospital leaders say. The 455-licensed-bed Holy Cross Hospital in Silver Spring, Md., like many hospitals, uses a variety of approaches to ED throughput "to make sure the sickest of the sick gets to see a doctor immediately," says James Del Vecchio, MD, FACEP, CMIO and medical director of the department of emergency medicine at Holy Cross.
To improve patient flow, the work begins as soon as a patient enters the hospital and is seen by a clinician, instead of sitting around and waiting to be registered. And quickly, the hospital separates patients having serious conditions from those who do not. By evaluating patients having "minor sore throats" for instance, "the hospital can siphon off 20% of 240 patients going to the ED on any given day," he says.
"Theoretically," Del Vecchio says, "those patients could have been seen at an urgent care clinic or have gone to a primary care physician, but may not have had one," he says. By redirecting patients who don't need ED services to an in-hospital urgent care center called Express Care, the hospital has a quicker response for patients with conditions, such as severe stomach ailments or potential appendicitis cases, who should be seen in the ED.
Of those patients sent to Express Care, the hospital counts 87% of those patients as "written for discharge at Express Care in 90 minutes," says Del Vecchio. "We are aiming for 90%, but still, it's pretty good," he says.
Hospitals like Holy Cross use other techniques to improve patient flow. For example, Holy Cross empowers nurses to begin taking tests on potentially more serious conditions, such as severe stomach pains or potential appendicitis cases. It stations a physician in an area near the ED for at least 11 hours a day to, in effect, conduct ED business without interfering with the ED, Del Vecchio says. "It's doing waiting room management so patients can be seen but not interrupt the flow." In the meantime, a multidisciplinary team coordinates other areas of the hospital, whether it's lab staff or housekeeping, to free up bed space and, Del Vecchio adds, to effectively reduce wait times.
Hospitals are trying new programs to deal with increasing numbers of patients visiting the ED and the resulting impact on wait times. From the moment patients enter an ED until they are discharged from the ED, the average time spent in waiting rooms nationally was 4 hours and 7 minutes in 2009, an increase of 4 minutes compared to 2008 and 31 minutes more than the national average in 2002, according to Press Ganey 2010 ED Pulse Report.
Hospitals don't see the situation easing any time soon. At least 32 million people who are currently uninsured will have coverage under PPACA—and hospital leaders can hope those patients get nonemergent care from a primary care physician and not the ED. But the country faces years of primary care shortages. The United States has about 350,000 primary-care physicians, but about 45,000 more will be needed by 2020, according to the Association of American Medical Colleges.
"My concern is if there are going to be enough primary care providers in place for them to go for appropriate healthcare," Del Vecchio says. "There will be an ongoing and worsening of the problem of the ED if there is a lack of primary care physicians."