Close the Waiting Room

Close the Waiting Room

Waiting rooms benefit doctors and nurses, not patients. If you add value to every minute for patients, you will not need a waiting room. Close it and use it for something else.

This blog/podcast covers the main points in Step 2 of No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments.

Hospitals spend thousands improving triage. They use Toyota’s LEAN processing to make triage efficient and quick. But none of it benefits patients if we send them from triage to sit in a waiting room.

Close Your Waiting Room

Triage acts like a dam, a bottleneck. It keeps patients out of the ED, until doctors and nurses are ready to see them.

It makes the inside of the ED manageable and organized. Patients inside the ED get care on stretchers, while everyone else waits their turn in the waiting room.

Waiting rooms make doctors’ and nurses’ work less stressful, but it does nothing to decrease the anxiety of those waiting with, potentially, life-threatening problems.

The triage dam turns the waiting room into a reservoir. Patients trickle into the ED one at a time, when providers are good and ready to see them. Waiting rooms keep chaos outside the main ED.

Bottlenecks

Eli Goldratt popularized the term bottleneck in 1984. Bottlenecks have a maximum speed that limits a whole production line.

We need to unblock, remove, improve, or put bottlenecks in parallel.

Doctors and nurses blame favourite bottlenecks: slow docs, slow nurses, admitted patients, sick calls, etc.

Instead of blaming things out of our control, we should try to put all ED processes in parallel. EDs need a quick, historic triage (sorting), but everything else can happen in parallel, at the same time.

Patients should go straight from triage into the main ED. If they can sit on waiting room chairs for hours, they can sit on chairs inside, where doctors and nurses work. We will discuss the details in the next Steps.

Close your waiting room and get patients inside the ED. The first doc or nurse available can see the patients, in no particular order. Get patients what they need as quickly as possible, just like a trauma case.

Objections

“But that will just increase patient volumes!”

“As soon as people find out they can get seen right away, we will be flooded with patients!”

“Besides, only really sick patients should come to the ED. We should educate patients to go somewhere else.”

a. Clusters of Emergencies; Idleness in Between

Picture a team working on a critically ill patient. How many people are in the room?

A patient who stops breathing needs 1 (or 2) doctors, 2-3 nurses, a respiratory tech, a clerk…and often many more staff to help at the same time.

Two patients arrest, at the same time, every few days in a busy ED. Three arrest at the same time, every month or two. Most of us can even remember a time when 4 patients arrested at the same time, or very close together.

We need at least 4 staff per arresting patient. If a large department needs to be ready to care for 3 and sometimes 4 arresting patients, at the same time, the ED needs up to 16 staff on duty.

But only a handful of patients arrest each day. What will ED staff do when they are not treating acutely ill patients?

Trauma rooms – special operating rooms staffed to manage trauma surgeries – face the same problem. Hospitals decrease the waste of having a trauma room ready by using the room for less urgent cases.

High efficiency EDs do the same. EDs pursuing the elusive dream of seeing only high-acuity patients waste resources.

b. Send patients to a clinic

Most ED patients could go to a clinic that had stat labs, urgent U/S and CT access, IV supplies, medications for acute care, nurses, a crash cart… An ED by any other name is still an ED.

Instead of sending patients away, many people talk about educating patients to go anywhere other than the ED. Step 4 tackles this issue in a section on ‘mental furniture’.

For now, if we want patients to go somewhere else, we need somewhere great for them to go. We should not berate patients for seeking care; it creates rotten attitudes in providers.

c. Costs vs. costs/case

Efficient organizations give great care for the lowest costs per case. Hospital boards love efficient EDs. Boards cringe at EDs with high costs per case, who chase mythical ‘high acuity only’ departments.

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I hope this super-short summary gives you a sense of what’s in the book.

Thank you to everyone who checked out the first blog/podcast!  You’ve already raised challenging questions that I will get to soon. Keep them coming!

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5 Replies to “Close the Waiting Room”

  1. Hi,
    I am a family physician in a rural Ontario. I have been thinking for a long time that we need to develop a education piece for patients about the appropriate use of ER and ambulances… I try point these things out to my patients who have attended the ER inappropriately. These things need to be thought in school! I’d have no issue with nurses turning patients away if they triaged as a 4 or 5….

    1. Thank you, Jen, for sharing your comment!

      You raise an important point that includes a couple of different issues. We have all heard the story about the guy in a remote area who gets an air ambulance ride into town because he has ‘chest pain’. Once discharged from the ED, he heads out to the beer store (his real reason for the ambulance ride). I’m not sure this story is true, but those who told me insist it is.

      For most people, I think they come to the ED because they need access. They do not come because they didn’t know any better. We need to provide great options for them to access care somewhere else, if we do not want them coming to the ED.

      As for triaging away, the auditor general found a 40% error rate in CTAS a few years ago. Also, I’ve seen cases of ‘sore throat’ that were sent to fast track who turned out to have acute epiglottitis or retropharyngeal abscess, or other other serious condition. They would have died if sent to a clinic. I could support Rx refills being sent elsewhere. But even that tends to encourage a dismissive attitude towards patients and the complaints that they worry about.

      Thanks again for taking time to read and share!

      Best

      Shawn

      1. Shawn
        Good article. thank you
        Education is as important or even more important as a fast MD
        Our group opened a walk in clinic now even on Saturday and Sunday taking in consideration that many people are of work. The clinic is opened from 10:00 to 18:00. We have 3 MD working in total. Guess what, the main bulk of patients falls on after 18:00.
        Chasing a tail is a useful physical exercise on personal level.
        If there is no appreciation there is no cooperation. we ought to stop treat patients like ” victims ” of an inefficient system and tell them “Hey ,guess what ,we are in the same boat, stop rocking it.”
        Regards
        Tatiana

        1. Thanks, Tatiana!

          I agree that education is important. Docs should do, “Fast things fast, and slow things slow.” Speed should never cut corners or produce inadequate care.

          Your observation from the weekend clinic is fascinating. No matter what you do, it will never be enough to meet the demand for a free service….exactly what the economists tell us.

          I like your comment about appreciation and cooperation. Why would patients want to cooperate or appreciate a free service? After a generation of free, free care becomes an expectation.

          I like your middle ground: stop rocking the boat. But I would push back a little on your ‘…stop treating patients like ‘victims’ of an inefficient system…’. I believe patients DO suffer from the inefficiencies of a centralized, top-down system. If patients could direct their tax dollars, if we had a truly patient-based funding system, then patients would command more respect from hospitals.

          But again, if it’s all just a free entitlement of citizenship…pretty tough to change.

          Thanks so much for taking time to read and comment!!

          Best

          Shawn

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