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To view 'The Myth of ER Overcrowding', please select the link below:
This presentation was created by Michael D. Berger, MD and uses Apreso for PowerPoint for online streaming capability.
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Not a day goes without some newspaper writing an article about ER overcrowding. Yes it is true that the number of patients utilizing Emergency Rooms for medical care has skyrocketed over the last decade. But overcrowded? What determines overcrowded? The most significant parameter and the one that most determines patient satisfaction is the delay in seeing the Doctor. When the problem is defined in these terms, the problem is more myth than reality in many hospitals. The problem of long delays in most hospitals is due more to the application of a 30 year old paradigm of how an ER should function rather than to insufficient staff and facility. If you throw enough money at a problem, it will go away. However, improved systems and management can have better results.
And why should we expect anything else? ER's are run by doctors and nurses who have lemonade stand level business experience. The current system evolved piecemeal as the number of patients arriving began to exceed the number of Gurneys available. The first Band-Aid applied was Nurse Triage. The result, another step the patient must traverse to see the Doctor. The problem is that the ER has become a long serial process. One step must be completed before the next can begin. Triage, registration, print the chart, chart to the box of patient's waiting for a Gurney, Charge Nurse pulls a chart when she realizes there is a bed, patient to the bed, nurse does an assessment (repeating the Triage Nurse's work), writes a nursing note, puts the chart in the "Doctor To See" box and when he notices it, the patient is seen by the Doctor. You think that was a run on sentence, imagine how it feels to the patient. This is why that it takes 2 hours to see the Doctor even when it is not busy. In our attempt to slap Band-Aids, we have institutionalized delay.
The answer is to reinvent the system by turning the current serial process into a parallel process. Most of these steps can be executed concurrently making the ER a parallel process. There is one requirement to accomplish this. The Doctor must see the patient on arrival so that everyone else in the system, nursing, x-ray, lab, etc, can get their marching orders up front. How do you accomplish this? The short answer is "Just do it". Of course to do it requires solving a number of down stream problems that rearranging the system will create.
First, you need to be able to print the clinical chart before registration. I accomplished this by an add on module to my EDNet tracking software that prints the ER Chart after entering only the patient's name and date of birth. The demographics and insurance information is added as a separate sheet after registration, which is now one of the parallel processes must only be done before the patient is discharged, not before being seen. The Doctor can then evaluate the patient, make notes and write orders at the time of triage or right after. Allowing a quick registration or again a software patch solves the next problem of getting the orders in the computer system before registration. This pattern will become familiar. Putting the Doctor up front will create downstream problems. Most of them I can predict and have solved. Some will be unique to the facility. However, I can say two things about every downstream problem. First, none are worse than the patient waiting 3 to 6 hours to see the Doctor and the second is that none are inherently unsolvable.
Next problem: not enough Gurneys. The answer is to realize that most of the patients who "overcrowd" ER's are not emergencies and don't require a Gurney. Most are there because of the inability to access office-based care. When was the last time you saw a Gurney in a Doctor's office? What is it about Bronchitis, Urinary Infection, Sprained Ankle, etc. that requires the usual "Patient in a Gown on a Gurney on a Monitor" model that has been traditional in ER's for 30 years. These are not emergencies. Get over it and give the level of care required and desired by the patient. There is nothing wrong with a chair. That's what you sit in when you see your Doctor. One of the often tried and frequently failed cures for long waits is the so called "Fast Track", "Express Care, "Prompt Care" or any other euphemism that promises but doesn't deliver. And why should we expect different. These ER off shoots are brought to you by the same people with the same systems that produced 3 to 5-hour ER waits. One hospital even issued pagers so patients could go home and be paged when it was their turn. Besides being a huge loss of pagers, I've never seen an ER Band-Aid that shouted "We give up" louder.
There's not enough space to cover all scenarios but let me give you an example from my ER. When I instituted this system, the average time to see the Doctor went down to 20 minutes and continued dropping to 7 minutes. Volume has been growing at a 25% rate into the second year but hospital collections increased at a 63% clip per year as better service attracted insured patients. Left Without Being Seen (LWBS) is usually zero. We added no Doctors but added PA's who were more than paid for by the previous LWBS. The hourly income to the Doctors doubled and Press - Ganey satisfaction scores went from 25th to 85th percentile. There was no increase in nursing coverage except as dictated by increased volume. The average turn around time for a discharged patient dropped to about 101 minutes. The hospital census, a previous problem, went to capacity.
Now what is it about reinventing the ER system that does not appeal to you?
If you are ready to break 'The Myth' simply contact me to find out how I can help...
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