Changing the face of emergency medicine.

"Slow night, eh doc?" my patient asks as I enter the room.

"Slow night?" I parrot back, perching myself on a stool to examine his injured right hand.

I knew what he meant. I just wanted to hear him say it.

Chitchat is not my strong suit, but I wanted to leverage his question into a sustained conversation.

"I just can't believe you're here so soon," he continued, adding again, "It must be a slow night."

I was glad to sit down for a minute, even if only to suture a wound. I had been on my feet for nearly eight hours. I was accustomed to hearing patients' expressions of pleasant amazement about the timeliness of their care, but I thought I would pursue this one a little further.

Our emergency department--a level-one trauma center and teaching hospital with about 38,000 patients annually--refocused its commitment to service excellence a few years earlier and our reputation was spreading. Still, this man intrigued me.

"Slow night?" I incredulously rehearsed in my mind as I began anesthetizing his wound. He had only been there a few minutes, but surely he had overheard the abusive outbursts of an intoxicated patient two curtains away and the page announcing the arrival of yet another trauma victim.

No, it was not a slow night. It was as busy as ever, but our commitment as physicians--and as an entire emergency department staff--was to see every patient within minutes of arrival.

True process improvement

Many health care providers speak of process improvements to better meet patient expectations, but few seem to think that a sustained and consistent effort can make such prompt attention to an emergency patient the rule rather than the exception.

Our experience has shown otherwise. We adopted the philosophy that waiting rooms are not for patients. Instead, we take our patrons from a brief triage directly into treatment rooms, where the first priority is to evaluate the patient and initiate care.

At last measure, our door-to-doctor times--the average time from when a patient walks into our hospital until they see a physician--was seventeen minutes (a 60 percent reduction from previous measures).

Registration comes later, at the convenience of the patient's bedside.

Since making these changes more than three years ago, we have not received a single complaint related to waiting. When I shared these processes and the results with a nurse manager of a large intercity emergency department, she asked, "How do you get your doctors to go into the room that fast?"

In short, it's a matter of commitment and priorities.

Where is there always a problem?

I recently heard a speaker ask an audience of physicians, "Where is there always a problem in the hospital?"

About half of those assembled answered back in unison, "In the ER."

"And what is the problem?" the speaker continued, lining up his audience for a dynamic discussion about problem-solving skills.

Answering back as quickly and uniformly as before, they shouted, "Waiting!"

Waiting, with its causes and consequences, is not just a perception of patients and families to be dismissed by the health care providers who "really know" what is going on. Much--perhaps most--of the waiting in emergency departments is a consequence of deliberate decisions that serve everybody except the patient.

One huge exception to that indictment, however, must be acknowledged. As long as social, political and financial pressures force uninsured and under-insured patients to seek care in emergency departments, the overburdened and under-compensated centers that usually provide these people with excellent medical care will be unable to provide the accompanying service quality which one might hope for.

Aside from that momentous and often discouraging situation, the generally ubiquitous problem of waiting in emergency departments has real solutions.

Tackling the problems of patient flow and waiting times is no harvest of low-hanging fruit on the service-quality tree. Rather, the changing culture of emergency departments mandates an evolution in the service model.

The old axiom, "If they're vertical, they're a customer; if they're horizontal, they're a patient," must change. There is a natural inclination to think of the most ill or most injured as the most important. This pragmatic approach is a function of necessity, but it also stirs the discontent of ambulatory patients who walk into an emergency department sporting the expectation, "simple problem, quick visit."

As long as this dichotomy in perceptions and expectations persists, so will the frustrations of patients.

Aligning expectations

Many have heard it--some have said it: "The reason patients are unsatisfied is because they have unrealistic expectations."

Challenging that assumption, the ingrained behaviors and attitudes of providers, may be more easily and more appropriately changed than trying to adjust, perhaps incorrectly, the expectations of an endless stream of patients who also happen to be customers.

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Take, for example, the Emergency Redesign Team at Harris Methodist Hospital in Fort Worth, Texas. Their commitment to change processes and attitudes found national attention when they redesigned their emergency department with the patient in mind and received the 1996 RIT/USA Today Quality Cup. (1)

Following our visit to Harris Methodist, our experience paralleled theirs and then continued on a course of patient-centered process improvement.

Though the opportunities to streamline and expedite patient care are myriad, some of our best successes include:

* Rapid triage and immediate care

* Care process models that initiate immediate order sets for common problems

* Bedside registration after the physician evaluation

* Fingertip access to a system-wide electronic medical record

* 24-hour, real-time radiography 

* Two-way radios to facilitate communication between team members

The benefits are real and they are noticed.

Now, around the corner from the suture bay where my patient queried me about his prompt treatment, a bulletin board displays more than 30 hand-written compliments from patients, accumulated over just the last few months.

How much is enough?

At the Ritz-Carlton's Legendary Service conference, the department manager asked me, "How do you get your doctors to go into the room that fast?"

The answer is "commitment."

Like every Ritz-Carlton employee who makes the hotel's famous service possible, every member of the emergency department team--especially physicians--must be committed. It never happens unless physicians are determined to actively support the effort.

I have heard emergency physicians unashamedly articulate their policy to never staff with enough physicians to eliminate waiting times. Such a policy maximizes profits, but it is not in the best interest of the patient.

When patient influx ebbs and flows, an overstaffed department inevitably sees quiet times when costs surpass revenue and employees sit idle. The easiest way to remedy this problem is to lop off the peaks in patient flow by stockpiling them in the waiting room to fill the valleys.

Then, things run smoothly and steadily, like putting a metered turnstile on the amusement park ride. As long as the seriously ill and injured are triaged appropriately, no one is ostensibly harmed. They just have to wait a little longer.

The depth to which such perspectives are ingrained into the emergency medicine psyche is epitomized by an article in the September 2003 Annals of Emergency Medicine. Investigating why patients leave the department without being seen, the authors asked about "15 specific services the ... ED could provide to help (patients) wait longer."

While acknowledging earlier studies that show that patients who leave without being seen often have serious medical conditions and "that the left-without-being-seen rate decreases when patient waiting time is decreased," the authors naively stated, "We could identify no study that has directly asked patients who have left without being seen what ED service, if any, might have kept them from leaving."

The answer, ironically, is contained in the very articles these authors cited--that is, provide care in a timely fashion and they will stay.

These authors, however, concluded that a more frequent communication to the patient of the estimated waiting times and the provision of immediate treatments (such as ice bags for contusions and bandages for lacerations) were two things they could do that "might increase the time patients are willing to wait." (2)

The great irony of this study and its conclusions bespeaks the problem and paradox of emergency medicine. It was the elimination of the wait by providing immediate care, even if only in the form of an ice bag or a band-aid, that kept the patients in the department.

And yet the authors concluded that if they could provide this immediate temporizing care the patients would be more "willing to wait." It is another example of the complete disconnect between patient and provider expectations.

We shouldn't be looking for ways to help patients settle-in for longer waits. We should be eliminating the wait. The wait is the problem.

While the level of service quality can be elevated by awareness and commitment, time and numbers eventually necessitate an increase in personnel. Better staffing means fewer and more manageable peaks with shorter waiting times, but such a suggestion may test the commitment of private-practice emergency physicians whose individual and collective pockets are impacted.

Cutting the pie into smaller pieces to pay more physicians is often an unpalatable proposal. Hospital management must share this commitment. Though employees may not appreciate the drain on the more nebulous pocket of the hospital, management must put their money where their mouth is when they ask for better service quality in the emergency department.

As a physician advisor to a heath insurance provider, I recently reviewed an informational packet prepared for clients. I resisted the inclination to correct the document that described long waits as a major disadvantage to utilizing the emergency department.

In reality, physicians in our department see most patients faster than they can be seen in their primary care provider's office, even when they have an appointment. In fact, patients often indicate that they come to our emergency department to avoid the delays they experience elsewhere.

Such service escalates our emergency department census, often with patients who have less severe problems. Such "abuse" of the system can fuel resentment by emergency physicians who feel they are being taken advantage of for the sake of convenience.

So, the changing culture and expectations of patients drives the need to change the model of service in emergency departments. We must view the person as a patient and a customer and serve these dual needs and expectations.

Improving the numbers

When emergency physicians unite in their commitment to see patients immediately, real and measurable results follow.

Despite a 32 percent increase in volume over the last four years, our turn-around times decreased 12 percent (from 183 minutes to 161 minutes) while our patient complaints have dropped 56.1 percent (from 2.1 per 1,000 visits to 0.92 per 1,000 visits--less than half the benchmark of 2 per 1,000 visits in similar teaching hospitals).

Our patient compliments steadily increased, while an independent consulting firm found that 44.8 percent of patients rated their care in our emergency department as "excellent" (compared to a national benchmark of 30 percent for teaching institutions).

All this happened despite the fact that our case mix index is the highest in the state and we are we are frequently forced to use gurneys in hallways to increase our capacity from 23 to 30 patient care positions.

Another independent survey--taken during our busiest months of the year--found 45.9 percent of our patients giving the department an "excellent" rating on service quality. Such success is not possible without sustained support from hospital administration and other departments.

For example, the collaborative efforts of patient care in our hospital reduced the time that emergency department patients wait for an inpatient bed from 75 minutes to 30 minutes. (3)

Our physician group, Salt Lake Emergency Physicians, at LDS Hospital in Salt Lake City, Utah, is fortunate that Intermountain Health Care (IHC) demonstrated a commitment to service quality and the cutting edge of medical informatics for years. This team approach serves both parties and, more importantly, the patient.

The emergency department can no longer be viewed as an incidental room in some corner of the hospital. As an increasing proportion of hospital patients are being admitted through the emergency department, and with the number of family and friends who accompany such patients to the hospital, the emergency department might well be considered the front door to the hospital.

Utilizing a growing body of national benchmarks and best-practice standards for emergency medicine, emergency physicians can work with all members of the health care team to lead the charge in changing the face of emergency medicine.

IN THIS ARTICLE ...

Discover how one hospital in Salt Lake City nearly eliminated patient waiting time in its emergency department and the department essentially became the front door to the hospital.

References

1. "ER workers help patients lose the wait," USA Today, 3 May 1996.

2. Arendt, Katherine W., et al. "The Left-Without-Being-Seen Patients: What Would Keep Them From Leaving?" Annals of Emergency Medicine, 42 (September 2003): 317-323.

3. Welch, SJ.; Allen, TL.: "Data Driven Total Quality Management in the Emergency Department at a Level One Trauma and Tertiary Care Hospital," Abstract presented at Research Forum, American College of Emergency Physicians Scientific Assembly in Boston, Massachusetts, October 2003. Abstract in Supplement to Annals of Emergency Medicine, 42 (October 2003): S58-S59.

Jeff O'Driscoll, MD, is chair of emergency medicine at LDS Hospital, Salt Lake City, Utah. He can be reached by phone at 801-408-1181 or by e-mail at [e-mail].

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By Jeff O'Driscoll, MD