Have you ever been the only customer in your local supermarket? Although the experience can be a bit unnerving, at first, you soon start to notice the advantages: No line at the deli, no pushy shoppers, no carts jamming up the produce section. As you breeze through checkout, you think to yourself, “Gee, I could get used to this.”
Now, imagine walking into an empty waiting area at your local Emergency Department. Although you might experience that same unnerving sensation, at first, you'd quickly notice some clear advantages. Within minutes, you’re registered, an I.D. band is placed on your wrist and you’re escorted into the treatment area. A well-trained physician greets you, examines you thoroughly, treats your problem and answers all your questions. As you leave the hospital in less time than it took you to drive there, you think, “Wow, I wasn’t expecting that.”
Of course, most patients never experience such rapid ED care, but it is possible. In fact, it’s been happening in some places for some time now.
About a decade ago, ED leaders at The Permanente Medical Group set out to change emergency medical care for Kaiser Permanente patients. The leaders turned to predictive analytics, new staffing models and a system-wide change in culture to speed up care delivery. And, for the past several years, patients have been seen in 10 minutes or fewer on average. Thus, for most of the day, the waiting areas (in EDs both large and small) are devoid of patients.
Of course, an empty the waiting area is just a perk. The real benefits include timelier care, improved patient safety and more lives saved.
These benefits are embedded in the story of a two-year-old girl who came into one of the Sacramento Valley Emergency Departments several years back. She arrived with a constellation of symptoms that, upon first evaluation, appeared viral.
Under the traditional model of ED care, the little girl would have been “triaged” (evaluated by nurse to determine the severity of her problem) and dealt a low-priority status. She and her mother would have waited behind dozens of other patients and, as more ambulances arrived, it’s possible the child might not have reached the front of the line for several hours. And under this model, she might have died.
But under the new model, the girl was brought immediately into the treatment area and seen by a emergency physician who took the time to evaluate her thoroughly. Slight stiffness in her neck led to a spinal tap. The physician quickly established a diagnosis of bacterial meningitis, a very serious and potentially deadly infection.
Within 30 minutes of her arrival, the child received intravenous antibiotics and, as a result, made a full recovery.
The following year, the girl’s mother sent a note, thanking the doctors and nurses for saving her daughter. Included was a photo from the girl’s third birthday party. Without doubt, the physician who cared for her deserves credit for helping the child survive. But he would not have had the opportunity to do so without the new ED model of care.
The Problem With The Traditional ED Model
The concept of triage dates back to the Napoleonic Wars. Given the enormous injuries and causalities inflicted on the battlefield, it was impossible to supply enough physicians to meet every soldier’s medical needs. Doctors, therefore, had to sort and prioritize patients by the severity of their injuries.
For centuries, triage has proven essential when patient demand spikes significantly, as in times of war or during natural disasters. These days, unexpected rises in patient volume, say a three-fold increase on a Sunday night, also necessitates triage. But this is rarely the case.
In reality, Emergency Department wait times reflect poor planning and weak leadership, not fluctuating patient demand. It’s no coincidence that ED delays are most pronounced on nights and weekends. That’s when patient demand is at its highest and it is also the least desirable time for ED doctors to work. Triage allows EDs to manage busier-than-normal patient volumes with less staff. So, patients with less-emergent needs end up waiting until later at night, when volume declines. As a result, today's patients spend an average of two hours in the typical Emergency Department, according to the Centers for Disease Control and Prevention (CDC),
Solving The Triage Problem
Contrary to the assumptions of the traditional model, ED demand can be predicted and appropriately staffed on most days, even during the busiest times.
Here are the three changes that proved most effective in Kaiser Permanente Emergency Departments:
1. Staffing to demand. Given the choice, patients prefer to come to the ED in the evening and on weekends to avoid missing work. They often come because their doctor’s office is closed and they have no local alternative. Although patient volume is higher during these times than on weekdays, demand is nonetheless predictable. The problem is staffing adequately.
Because doctors and nurses prefer to work weekdays, during normal business hours, most EDs are relatively understaffed during off-hour peaks. This creates delays at the busier times and wasted resources during slower times. By studying patient volume over time, EDs can avoid triage by staffing appropriately and more accurately. Here are two ways KP has done so:
2. Redeploying the nursing staff. To assess whether a patient has a true emergency, nurses who register patients ask the same questions doctors do upon admission. Therefore, the triage process wastes the time of skilled nurses who could be providing definitive medical care. By moving the nurses from triage into direct patient care, and making the physician the first point of contact after patient registration, EDs can bolster the number of medical professionals providing treatment and, therefore, treat patients quicker.
As part of the approach, EDs can utilize lower-cost support staff to care for the kind of less-emergent patient problems normally treated by community doctors in their offices. Doing so further frees up registered nurses to treat the sickest patients.
3. Modifying physician staffing. In small EDs, there may be only one or two doctors on duty at a time. In larger departments, there can be four or five. So, rather than insisting all ED doctors be board-certified, EDs can pair emergency physicians with family medicine practitioners or internists whose training adequately prepares them for the definitive treatment of non-life-threatening illnesses. This approach enables EDs to increase staffing without increasing budget, and it makes more physicians available to see patients as soon as they arrive.
If everyone coming to the ED had a life-threatening problem, this model wouldn’t work. But a significant percentage of people don’t. By staffing appropriately for the acuity of patient problems, doctors can treat and discharge those with less-emergent issues faster. Having a single extra physician available during peak hours means that as many as 30-40 more individuals can be seen without delay compared to the current approach.
So, why hasn’t the new model become standard practice? Doctors and nurses tend to resist changes to their care-delivery methods, insisting that the old way has worked for centuries. The truth is, forcing patients to wait in the Emergency Department is unnecessary and dangerous. Improving patient flow can and does reduce hospital costs while improving clinical outcomes.
Correction: This article previously referenced a pediatrician providing care to the child referenced above. The care provider was an emergency physician in a Sacramento Valley ED.
