Improving Emergency Room Performance
When I took my husband to a local Emergency Room earlier this year for what was finally diagnosed as an illeus, I was asked if he showed any signs of a heart attack. Not knowing what was wrong with him (and it took seven hours for the ER staff to determine the cause of the intense pain), I said he had had pains around his chest area (true) but I also realized that he might be seen sooner; the emergency room at 9 pyem on a Saturday night was, not surprisingly, crowded. Because of that answer to the question, he was separated from the collection of assorted ailments on view that might have been considered less immediate in nature by the staff. My husband then spent the next five days in the hospital. This anecdote is to illustrate that the ER can be a foreign country and a passport and efficient method to traverse it are needed.
The Commonwealth Fund, a "Private Foundation Working Towards a High Performance Health System", has produced a report Emergency Department Operations in Top-Performing Safety-Net Hospitals. Selected paragraphs from its overview, findings and executive summary reveals the following points:
Overview
This report profiles five safety-net hospitals — Boston Medical Center, Denver Health, Memorial Regional Hospital, Memorial Hospital West, and Virginia Commonwealth University Health System —that made improvements to curb emergency department (ED) crowding, reduce long waits, and lower the number of hours spent on ambulance diversion. Hospitals used a combination of interventions, including: reconfiguring the ED to maximize efficiency; devising a pre-diversion system to alert staff of ED crowding; installing an electronic tracking system; designating staff members to be responsible for tracking patients; and developing meaningful performance metrics. To be successful, such interventions need to take place within a broader improvement strategy that entails: recognition that ED crowding is a hospital-wide issue; leadership provided by the CEO and other senior staff; vigilance in pursuing change, reviewing outcomes, and working to improve; transparency; and a commitment to quality for safety-net populations.
Key Findings:
Successful Throughput and Output Initiatives
The study hospitals used a combination of interventions to promote the smooth and timely flow of patients through the ED and other departments, known as "patient flow." They have seen improvements in a number of measures, including greater patient satisfaction, better patient care, reduced waiting times, decreased costs/increased revenues, and less time spent on ambulance diversion. We identified five strategies to improve quality and efficiency in the ED. Some do not require significant investment and therefore could be undertaken by many hospitals, including those that are challenged financially.
Reconfigure the ED to maximize efficiency. The study sites have undertaken a range of physical improvements in the ED, from a simple reorganization of ED triage and treatment rooms to a whole-scale redesign and rebuild. Even small redesigns such as identically equipping ED exam rooms or color-coding ED treatment room trays can produce efficiencies.
Devise a pre-diversion system to alert staff of ED crowding. Several of the study sites devised systems to signal that the ED is nearing diversion status. The alert triggers a communication strategy throughout the hospital that inpatient beds are needed for patients in the ED, in order to make room for incoming ED patients.
Install an electronic tracking system. Study sites that have installed electronic tracking systems have found them to be an invaluable tool for managing patient flow. A tracking system enables a manager to easily identify rooms that are empty, those that need to be cleaned, and those that house a patient ready for discharge.
Identify individual(s) responsible for tracking patients. Some sites have created a "bed czar," or bed facilitator position, to oversee patient flow throughout the hospital. This individual is empowered to communicate with the ED, medical departments, and hospital floors to smooth and expedite patient transitions between departments and through discharge.
Develop meaningful metrics. The hospitals emphasized the importance of developing metrics to measure, analyze, and improve performance. This strategy is crucial to establishing baseline performance and setting improvement goals. Hospitals can begin this work with a small set of measures, limited to specific departments or conditions, and expand as they gain experience and expertise.
The entire report by L. Nolan, M. Regenstein et al., Emergency Department Operations in Top-Performing Safety-Net Hospitals, The Commonwealth Fund, July 2009, can be read at the Commonwealth Fund site.