The emergency department is one of the most critical departments of a hospital as its patients contribute to a significant portion of the hospital's revenue. However, emergency departments are notoriously difficult to staff as the influx of patients can be tricky. Mark Harris, MD, FACEP, senior vice president of the emergency medicine division of TeamHealth, believes that rational metrics of success for emergency departments are "door-to-doc" times less than 45 minutes, LWOTs (patients who leave-without-treatment) of less than 2 percent and lengths of stay of less than 180 minutes.
As public health threats, such as H1N1, plague EDs, it is critical that departments use best practices, including the following five, in an attempt to meet these benchmarks and treat patients as efficiently as possible.
1. Incorporating demand-to-server staffing models. Although the arrival time of patients to the ER can be random, staffing shouldn't be. Arrival patterns can be traced and staffing adjusted accordingly using theories, such a queueing theory (the study of people waiting in lines) designed for these purposes.
"Anytime someone is 'waiting' in an emergency department, you have a queuing problem," says Dr. Harris. "In the ED, a queuing problem would exist when the demand of patients is greater than the capacity of a given server to process them. A 'server' is simply a person (nurse, physician), department (x-ray, lab) or thing (bed, hospital floor) which performs a service to arriving patients. When distilled to the simplest common denominator, the ED is a network of servers all of which perform a unique service to a patient. If any of these servers is unable to process patients faster than they arrive, the department will back up all the way to the front door."
Until recently, healthcare institutions did not have the tools to identify which of the many ED servers were not aligned to the demand of arriving patients. However, software programs are now available to assist nurse managers and medical directors in identifying which servers are not aligned to the given demand of arriving patients. The use of such software will most certainly become a new paradigm in managing emergency departments, says Dr. Harris.
"Parenthetically, when an ED server is identified as not having the capacity to meet the demand of arriving patients, it does not always mean that you have to 'add more staff' or 'add more beds.' By combining queuing theory with Toyota’s LEAN process improvement and Motorola's Six Sigma methodology, you can identify ways to 'off-load' servers so they become more productive," says Dr. Harris.
For example, if a triage nurse can only evaluate six patients per hour (meaning that he or she spends about 10 minutes to evaluate a patient) but the average arrival rate is seven patients per hour, EDs will develop a queue, and, eventually, people will begin leaving. However, if the department was to introduce a concept called 'mini-triage,' in which the triage nurse only asks the chief complaint, obtains the vital signs, calculates the Emergency Severity Index and obtains the patient's medication list, the triage nurse can now see 10 patients per hour which immediately unclogs the ED without any additional staffing costs.
Finally, determining how much staff coverage an ED needs must be based on the arrival-by-hour pattern of patients, says Dr. Harris. With typical arrival patterns, you will need more staff in the afternoons than you will need on night shift.
"This sounds rather simplistic, but, in fact, nothing could be farther from the truth. One reason for this is that there are considerable variations in the number of patients arriving to the ED by hour of day. Simeon Poisson, a French mathematician, noted that if, on average, four patients arrived to your ED on any given hour of the day, that at least 16 percent of the time, five patients would arrive. Additionally, Poisson predicted that 11 percent of the time, six people would arrive, and so forth," says Dr. Harris. "Because of this, you cannot just staff for four patients an hour, or at least 27 percent of the time, you will be understaffed. Thus, you need a little extra capacity to allow for the random variation in arrivals-by-hour in the ED."
In like fashion, provider capacity is based on productivity or server rate. Here there is often considerable variation based on the varying complexity of patients. For example, if a physician can see two patients per hour, this means that, on average, he or she spends 30 minutes on any given patient. However, sometimes a complex patient may consume 60 minutes of a physician's time. Because of this, extra capacity must be built into your staffing solutions or waiting will occur, according to Dr. Harris.
"In the very near future, the use of queuing software will become paramount to staffing-to-demand given the complexity of the mathematical computations required," he says.
2. Get patients out of the waiting room as soon as possible. Reducing wait times is the surest way to improve LWOT rates, so it is important that EDs aim to get patients out of the waiting room quickly and into beds or other waiting areas.
"There needs to be a culture where there is a bias for taking LWOT rates down to the lowest possible level, says Lynn Massingale, MD, FACEP, executive chairman of TeamHealth. "A significant portion of [LWOTs] are going to have a medical problem that will not get treated, which is a risk management issue, while another portion is going to go somewhere else, which means lost revenue to the hospital."
Dr. Massingale recommends that ED staff move patients to ED rooms as soon as possible, even if that means doing triage and registration at the patient's bed.
Other times this can mean just sending a patient to a sub-waiting area, such as when waiting for lab result, says Dr. Massingale. "We want to get you back and get something going even if you don't want or need to occupy a bed," he says.
3. When staffing models and processes fail, transparency will go a long way. Sometimes public health crises or other events can disrupt an ED, increasing wait times and decreasing efficiency. In these cases, being transparent about wait times and using "common sense plans for managing" can reduce patient restlessness and possibly reduce the amount of patients who go elsewhere for treatment, says Dr. Harris.
According to Trudy Lane, RN, senior vice president of operations for TeamHealth's Midwest division, simple fixes can go a long way. She suggests employing Quint Studer's principles of "Hardwiring Excellence," which encourage healthcare providers to take simple steps to improve care and increase patient satisfaction.
Dr. Harris says that following this process can yield big benefits. "Updating patients on wait times, rounding on patients in the waiting room, introducing yourself each time you enter a room and saying thank you will go a long way when other systems fail to help soothe the patient experience," he says.
4. Hire scribes to assist physicians in documentation. Scribes, a once popular solution to reducing physician documentation responsibilities, have returned in the ED after falling out of use for some time.
"Scribes are often energetic young students with an interest in medicine, such as medical or nursing students that do the documentation part of what a physician does. They essentially make physicians more effective by allowing them to use more of their time to actually treat patients," says Dr. Harris. "Anything that takes a physician away from direct patient care reduces efficiency. If a physician typically sees two patients per hour, even five minutes of additional administrative work drops that physician down to seeing 1.75-1.8 patients per hour."
Scribes document patient charts, retrieve lab results and complete other administrative work typically done by physicians but at much less of a staffing cost.
Scribes can also assist nurses in their documentation duties if the department is nearing capacity. "Nurses may spend 60 percent of their time documenting, and the use of scribe or tech can take that off load work of nurses," says Dr. Massingale. "Nurses need to do the things they were trained to do, and the same for physicians. A physician typically doesn't enjoy completing documents, making phone calls and gathering labs. Productivity drops and they're not happy, neither of which is good for a department."
It's important to note, however, that the use of scribes is not necessarily appropriate for every emergency medicine group. One must evaluate a number of factors, including capacity levels, to determine whether it is the right solution for a particular hospital.
5. Always document vital signs upon discharge. Emergency departments should also implement a careful policy to document vital signs at discharge — a policy which can greatly improve quality of care and reduce the likelihood that the patient will re-present to the department.
"Most of us believe, and research appears to, show that patients who leave with abnormal vitals, including blood pressure, heart rate or temperature, have a significantly higher chance of having a poor outcome than a patient with normal vitals," says Dr. Massingale.
Dr. Massingale says that sometimes patients are discharged with abnormal vitals because of assumptions made by ED staff. "A nurse will assume a doctor is aware of an abnormal pressure or heart rate and the doctor assumes a nurse will catch it, but then no one catches it and the patient could come back with a heart attack or stroke," he says.
To prevent this from occurring, Dr. Massingale recommends hospitals have a formal policy for taking vital signs at discharge. Departments should set standards for abnormal rates. For example, if rates are abnormal, a nurse must communicate it to the physician before the patient can be discharged. In some cases, the physician might be aware and move to discharge the patients, such as if a patient has a high heart rate but recently received a shot of epinephrine. However, the policy can greatly reduce a hospital's risk for reducing patients that are not ready to be discharged, says Dr. Massingale.
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