HealthLeaders Media Rounds

Jim Molpus, for HealthLeaders Magazine , April 8, 2010
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HealthLeaders Media gathers experts at Scripps Health to map a plan for ED overhaul.

Hospital emergency departments have always had a unique dynamic that is more frenetic than most others parts of the hospital. The challenges will only grow, as lack of access continues to increase the number of patients who view the emergency department as the front door of the hospital. Despite any old or new challenges, leading hospitals are finding ways to increase satisfaction for patients and staff alike. HealthLeaders Media gathered experts from William Beaumont Hospital in Michigan, Methodist Healthcare in Memphis, and Tomball (TX) Regional Hospital on the campus of Scripps Health in San Diego for a unique interactive half-day seminar on Feb. 23.

Chris Van Gorder, FACHE, president and CEO of Scripps Health and chairman-elect of the American College of Healthcare Executives, said that the challenges facing hospital emergency departments are well known, but that the results are often overlooked.

"The physicians, nurses, and administrators we have in emergency departments ought to be congratulated for actually maintaining services in the challenging environment in the United States today," Van Gorder said.

It's the hospital, not ED
The image of hospital emergency department patients lying in hallway beds is an aftereffect of a system that is stretched to capacity. But the solutions to managing patient flow and throughput are often not to be found in the emergency department itself.

To borrow a surgical term, "The emergency department is not the obstructing lesion," said Brent Eastman, MD, FACS, chief medical officer and N. Paul Whittier chair of trauma at Scripps Health and chairman of the board of regents of the American College of Surgeons. "The obstruction, we have learned, is really upstream from that in the hospital. Until we remove that we are going to have a problem just focusing on the emergency department."

To manage the conflicts that come when beds need to be free, Scripps appointed a coordinator—known affectionately at the "bed czar"—to oversee systemwide bed flow so that there is a single person who has the authority to free up bed space.

Others still use a group approach, says Jedd Roe, MD, chairman of emergency medicine at William Beaumont Hospital in Royal Oak, MI.

"We are not quite to the single-person level yet," Roe says. "We have created what we call a daily operations group. It began with a recognition by our CEO that this was a hospitalwide problem, so we all needed to participate in the solution. So we bring together leaders from every department and every floor of the hospital for 15 to 20 minutes every day to look at the data from the day before and to anticipate bed needs going forward and where we can intervene in time rather than wait until 3 or 4 in the afternoon when it really hits the fan."

Tomball Regional Hospital uses a combination of both, says Robb White RN, CEN. "We've actually taken a morphed view of this. We use both structures. We meet every morning at 9 a.m. We invite all the people there but we have a resource nurse that is a 'czar' for us, and they are tasked with making sure what we decided to do is executed."

Part of any effective program to manage ED flow is to understand when patients tend to arrive and the bed needs that will correspond. Roe uses "queuing theory" to understand how to manage a patient arrival curve that is much the same at every hospital. "We all have the same shaped curve," Roe said. "And you can see that as you project a time after arrival at which time they will need a bed, that is about four hours after they arrive. This curve is eminently predictable and it is the same every day of the week."

The satisfied ED patient
Patients with a bad experience in the emergency department often cite wait times as their primary complaint. But Roe says that often it is not the actual wait time but the patients' perception of it that causes the problem.

Beaumont is among hospitals that use data on average wait times to calculate how long a patient may have to wait for labs, or a CT, or any number of other procedures. Behind that data is a carefully crafted script of responses that nurses, physicians, techs, and other caregivers use to communicate to patients how long they should expect to be in the ED.

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