Thursday, June 26, 2008

Every Second Counts

Long waits in an emergency department can make the difference between life and death

By Zabihullah Noori and Tiffany Tcheng

Kelton Aker knows what it’s like to wait in an emergency room in unbearable pain. In the summer of 2006 Aker, his wife and a few cousins were camping in Arizona’s White Mountains. While playing Frisbee, Aker slipped and fell. “I knew something was wrong because I couldn’t breathe,” he said. He suspected he had a collapsed lung.

The closest hospital was in Springerville, a town about 40 miles away. Aker knew the small rural hospital couldn’t handle the case, but it was the only option. A friend drove him there as fast as he could.

Aker waited 30 minutes for a chest X-ray. The results showed that two severely broken ribs had punctured the plural cavity, causing his lung to collapse.

He wanted to be transferred to Yavapai Regional Medical Center in Prescott, closer to where he lived. But Yavapai Regional didn’t have a level-one trauma center, so Aker was airlifted to Banner Good Samaritan Medical Center in Phoenix. It’s one of seven level-one trauma centers in Arizona—five in Phoenix, one in Tucson and one in Flagstaff.

A small plane carried Aker and his wife to Sky Harbor International Airport in Phoenix. By the time they landed, he had endured four hours of severe pain. A team at Banner Good Samaritan treated him immediately. Five days later, he was discharged.

Aker’s ordeal lasted many painful hours because he was injured in a remote location, but he actually spent only 30 minutes waiting in the emergency department (ED)—and that was for an X-ray. Not everyone is so lucky.

According to the Los Angeles Times, Edith Isabel Rodriguez died of a perforated bowel in 2007 while waiting in the ED at Martin Luther King Jr.–Harbor Hospital in Los Angeles. A video shows her thrashing around on the floor in her own blood and vomit for 45 minutes. A janitor cleaned up around her, but no one tried to help.

Rodriguez’s case brings into question the care that patients receive in the emergency department during their most traumatic moments. Once reserved for urgent situations, EDs are being used more and more as primary care facilities. The result: longer wait times.

But pointing fingers at just one factor is unfair. EDs are complex. Long wait times also stem from staffing shortages, population growth, uninsured patients and design factors.

Shrinking EDs

In Arizona the number of emergency departments hasn’t kept up with the rapidly growing population. “You don’t see a lot of emergency departments growing in size,” said Davey Ellison, nursing director of the Emergency Department at Banner Estrella Medical Center in Phoenix.

In fact, ED staffs are shrinking. As more and more people swarm the ED, the patient-to-physician ratio becomes smaller. And the wait times grow longer.

Some 10,000 physicians were serving an estimated population of more than 6 million Arizonans in 2006, according to the Arizona Department of Health Services and the U.S. Census Bureau. Of those 10,000, only about 500 were emergency physicians.

The University Medical Center in Tucson is in danger of losing its level-one trauma status because of the limited supply of surgeons. These physicians are always on call. “The lifestyle of a trauma surgeon isn’t the one that works well with a nice lifestyle,” said administrative director Michele Zimba.

A shortage of ED nurses also contributes to long waits. “Many hospitals will not allow a new graduate out of nursing school to work in an emergency department because the patients are too sick and they don’t have enough experience,” said Dr. Bob Dietrich, an ED physician at the Mayo Clinic in Scottsdale, Ariz.

But even experienced nurses can handle only so much. Ellison estimated that ED nurses get burned out after five years. When they leave, the ED loses valuable experience and knowledge.

Some ED nurses stay much longer. Caryn Unterschuntz, who was an ED nurse for 19 years in the Chicago and Phoenix areas, avoided burnout by moving around to different hospitals. “People either like ER, or they don’t,” she said. “The people who like ER like critical thinking and problem solving.”

To offset the physician shortage, Ellison hires nurse practitioners and physician assistants to help out in the ED so patients are seen quicker. Often, when patients are discharged from the ED, they’re instructed to follow up with a primary care physician within two to five days. But they usually can’t get an appointment in that timeframe, so they end up in the ED again.

Unterschuntz recommended giving nurse practitioners an office in the ED, where they can see referrals from busy primary care physicians. “It’d provide excellent follow-up for the patient and alleviate [trying to get into a primary care office],” she said.

Staffing at Banner Estrella depends on patient arrival patterns, such as the time of day and the day of the week, and the severity of the patient’s condition. Based on those patterns, overlapping 8-hour, 10-hour and 12-hour shifts accommodate patient and staff needs during the busiest times.

To retain ED nurses, Ellison allows them to choose between shorter shifts more days a week ands longer shifts fewer days a week. Experienced nurses screen patients to determine their acuity level. This keeps the flow of patients moving and results in higher patient satisfaction scores.

The experienced nurses also teach newer ones. “They love it,” Ellison said. “They get to teach, and they don’t have to stand” as long as they would if they were working an ER shift.

Primary care facilities

Also contributing to long waits is the fact that the ED is turning into a primary care facility. On average, 219 people visited an ED in the United States every minute in 2005, according to the National Hospital Ambulatory Medical Care Survey. Many of them didn’t have insurance, so their only option was the ED. The U.S. Census Bureau estimates that about 47 million people in the U.S. are uninsured. That includes more than a million people in Arizona alone.

But it’s not just the uninsured who are crowding EDs. A recent study in the Annals of Emergency Medicine attributed increasing ED usage to patients who have had complications after a medical or surgical procedure and then go to the ED because they can’t schedule a timely appointment with their own physician.

Dr. Dietrich estimated that nearly 70 percent of the ED patients at Mayo come in with non-emergency problems, such as the flu or back pain. Patients with life-threatening conditions are seen first, forcing those with less severe ailments to wait longer.

“Patients [should] understand that they don’t go to the emergency department unless they have an emergency,” he said.

Unterschuntz said “minute clinics,” or the medical clinics located inside Wal-Marts, might reduce the patient volume in the ED as people get used to stopping there for a backache as well as a backpack.

The time of year and holidays, such as Christmas and Thanksgiving, force people to rely on the ED because primary care facilities are closed. Wait times are also longer during cold and flu season—or during Arizona’s blistering summers, when people suffer from heat stroke.

But no matter why patients come to the ED, they should receive quality care. “We want to know that we met your expectations,” Ellison said, “regardless of what you’re here for.”

Designing an ED

To shorten wait times, hospitals across the nation are using a form of split emergency department. First, a nurse determines the severity of the patient’s condition. Those who are bleeding or showing symptoms of a heart attack, for example, are sent to acute care. The others go to the intake area. About 70 percent of admits at Banner Estrella end up in the intake area for tests, lab work and other medical screening.

People tolerate waiting better if they understand where they are in the check-in and treatment process. To keep patients informed, Banner Estrella implemented the Next Step Process in May 2008. Maps of the ED in English and Spanish are posted throughout the area. Dots indicating “You are here,” like those on shopping mall maps, show patients where they are in the ED process and what the next step will be. Patients also receive a diagram of the ED and a brochure describing each step in the process.

One time-saver is the electronic medical record system. Instead of relying on intermediaries like lab or pharmacy techs, physicians themselves order the lab work, tests and prescriptions. This reduces transcription errors. Lab and test results show up on the electronic medical record immediately, thus eliminating the need for someone to run lab results to the physician or nurse. Healthcare providers can obtain full patient histories through the electronic medical record system. Thanks to state-of-the-art medical imaging equipment, the turnaround time on lab tests is very good, Ellison said.

Scottsdale Healthcare in Scottsdale, Ariz., posts the ED wait times on the home page of its Web site for its three facilities. The information is automatically updated every 10 minutes.

Although the wait time can’t be guaranteed when the patient arrives, it helps people decide where to seek treatment.

Even with these time-savers, patients still have to wait. Comfortable surroundings can ease anxiety and pain. Banner Estrella recently recovered its weathered chairs and painted the waiting room in pleasing earth tones. The floor tiles were replaced with terracotta-colored rubber, which is gentler on the feet. Complimentary coffee and a wall-mounted television make the wait a little easier. The walls outside the ED will be covered in slate tile to make the area feel more welcoming. Additional housekeepers were hired to keep the ED tidy.

From the bottom up

No matter how comfortable the ED, the most important thing is that patients feel they’re being cared for. One way to ensure quality is by fostering good teamwork. “You can have any design, any workflow process,” Ellison said, “but they’re only going to work if you have the right people [working], and everybody does it together.”

Another way to improve quality is by soliciting feedback from many sources. “For years we’ve had people at the top telling us how to do our jobs,” said long-time ED nurse Caryn Unterschuntz. “And now we need to start looking at the workers who are doing the jobs because they know how to improve the situation….They can save the companies money and find better practices.”

The next time a hospital is considering an expansion, Ellison suggested consulting a management engineer to evaluate and assess the flow in the ED, including the nurses and staff who care for the patients. Feedback from patient satisfaction surveys could be taken into consideration as well. After a thorough study, the engineer can relay the information to the architect.

“That way, we’re not designing our process around the building,” Ellison said. “We’re designing the building around the process.”

Click on the headline to visit the Healing Web site.


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