Despite long waits and boarding, hospital EDs can keep patients satisfied

Overcrowding in hospital emergency departments leads to low patient satisfaction which, in turn, becomes a financial punch in the gut for clinicians, as compensation incentive plans are tied directly to satisfaction scores.

In a Nov. 7, 2022, letter to President Joe Biden, the American Medical Association, American Nurses Association and dozens of other medical groups warned staffing shortages have brought emergency department boarding to a "crisis point."

It's four months later and the crisis is still "awful."

Boston-based Massachusetts General's Chief of Hospital Medicine Melissa Mattison, MD, told CNN Feb. 6 that hallways are "lined with dozens of patients waiting to get a room upstairs. Everybody's doing their best, but where do they go to the bathroom? How do they take a shower if they want to clean up? How do they eat? There's no privacy. It's just, it's awful. It's absolutely awful."

If you are thinking "there's nothing I can do about patient volume in the ED," technically you may be correct. Conditions are beyond physicians' control. 

Anecdotally, however, ED providers can have a positive effect on patient experience (and, thus, compensation incentives) by keeping in mind the questions Press Ganey asks in patients regarding clinician concern for their comfort and being kept informed about treatment.

Several ED chiefs told Becker's that it's important for physicians to not ignore the proverbial "elephant in the room" — namely, frustration over long ED wait times.

"Address long wait times head-on by saying, 'I know you have been waiting, and I want you to know that now I am here, and it is now your turn to get our full attention on you and how to care for you,'" said Lance Becker, MD, chair of Northwell Health's Department of Emergency Medicine in New Hyde Park, N.Y. 

Zebulon Timmons, MD, division chief of emergency medicine at Omaha, Neb.-based Children's Hospital & Medical Center, echoed that sentiment. "When rushed, it becomes the path of least resistance to see a patient, order diagnostic studies, and then return only once all those initial tests have resulted. This leaves the patient's family, who are understandably worried about what those test results might be, feeling abandoned for a considerable length of time."

Becker's asked Dr. Becker and Dr. Timmons and three others for actionable initiatives that can and should be put in place, today, to improve patient experience. 

Editor's note: Responses were lightly edited for clarity and length.

Lance Becker, MD. Chair of the Department of Emergency Medicine at Northwell Health (New Hyde Park, N.Y.): Achieving some of the most meaningful changes in the emergency department can be straightforward; it comes down to making our patients feel valued. Nurses and doctors rush in and out, often interrupting the patients or giving off the impression that we are too busy. Shifting how we communicate, even in the slightest way, can significantly impact the patient, quality of care and overall morale.

For example, when meeting the patient for the first time, a clinician should consciously avoid interrupting the patient after asking them the typical initial open-ended questions such as, "What brings you in today?" Studies have shown that in the emergency department, physicians frequently interrupt the patient with a clarifying question like "Oh, you said you have pain. Where was the pain?" It is better to listen intentionally for a while, as you ultimately get more information and by listening than by interrupting to dig out the details immediately — there is time for that later. 

Bradford Borden, MD. Chair of the Emergency Services Institute at Cleveland Clinic: We have initiated three practices to improve patient care and ultimately the patient experience. First, we have placed a provider in triage to initiate orders for patients. This has improved early access to diagnosis and treatment and decreased our "left without being seen" numbers as patients experience fewer delays.

We also have instituted dedicated patient schedulers to arrange follow-up appointments with primary and specialty care. This has helped prevent avoidable admissions and has ensured that our patients are getting appropriate follow-up consultations.

Finally, we have initiated a call-back program in which our caregivers, including physicians and nurses, call to check on patients who were discharged from the emergency department. This has been extremely well received by our patients.

Toni Gross, MD. Chief of the Emergency Department at Children's Hospital New Orleans: Waiting time is wasted time. Using wait time to provide health-related education can transform some of that waste into something meaningful and distracts from the waiting. Health educators would be ideal, but educational movies or video games are also tools to consider.

One of the most frustrating things about being a patient in an emergency department is not knowing what you are waiting for. Having staff available to keep patients updated on the course of the visit makes the wait more tolerable. There are innovative technology solutions that may be able to do this as well.

Cleanliness and sanitation is an easy win to demonstrate the hospital's commitment to the health and safety of patients. Dedicated personnel to ensure cleanliness allows the clinical staff to focus on providing care.  

Karthikeyan Muthuswamy, MD. Assistant Medical Director of the Emergency Department at Virginian Mason Franciscan Health's St. Clare Hospital (Lakewood, Wash.): An actionable way we improve patient experience is by effectively managing our resources through various tools including our Mission Control Command Center. It provides visibility into various capacity metrics from staffing levels to available inpatient beds. Utilizing these tools and metrics, we can make informed decisions to ensure we provide the best care possible to our patients.

Zebulon Timmons, MD. Division Chief of Emergency Medicine at Children's Hospital & Medical Center (Omaha, Neb.): A big component of patient and family dissatisfaction is decreased face time with nursing and providers when the department is busy. But simply asking staff to spend more time at the bedside will typically fail, as the demands of the ED will inevitably pull them away without constant reinforcement. A better approach is to find ways to standardize the check-ins with patients. 

One way that has been successful at our institution is hourly rounding by the charge nurse. Other options include emphasizing your unit vital sign policy and making sure you are asking if the patient has any needs at those times. I do think there is an opportunity for providers to be checking in more regularly.

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