5 Ways to Reduce Healthcare Spending on Emergency Departments

MC900434829ED visits are growing.

ED costs are growing.

If the ED was a bakery, we could send customers away at the front door when the pastries were gone.  Some still suggest this dangerous practice.  Here are 5 better ideas that will work.

5 Ways to Save $$ on EDs

1. Increase access to imaging and labs.  A patient can’t wait weeks to find out whether the lump in her breast is a cancer or headache is a tumour.  Patients come to the ED even though they’d often rather go anywhere else.

2. Provide clinics for ‘in-between’ patients (CTAS 3).  On a scale of 1 to 5, CTAS 3 patients aren’t dying but have more than a sunburn.  These patients needs tones of care and investigations.  A few are acutely ill, but most suffer from chronic issues.  Either give them direct access to clinics, or let emergency physicians send patients directly to specialty clinics (same day appointments).

3. Get admitted patients out of the ED.  Admitted patients get horrible care in the ED and cost the most, by a very wide margin. ED care costs more than ward care.  Get admitted patients were they can get the care they need: up to the wards!

4. Don’t transfer dying patients to the ED who never wanted to come to the hospital in the first place (signed advanced directive).

5. Close EDs.  In Canada, we close rural EDs and refuse to expand the size or number of EDs to keep pace with population.  It’s a terrible option for customer service, but it does save money. 🙁

What do you think?  Click Leave a Reply or # Replies below.

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ED Efficiency: High Acuity vs. Volume

MP900182789Myth survives as common knowledge. Healthcare sages propagate emergency department (ED) efficiency myths like:

“If the ED only saw ‘true-emergencies’, ED crowding and costs would improve.”

“Many patients don’t need to be in the ED.  We would save money by sending them somewhere else.”

The myth of High-Acuity, ‘true-emergency’ EDs assumes:

1. It’s possible to educate patients to go elsewhere.

2. Patients have somewhere else to get care.

3. Staff can safely tell who is a ‘true-emergency’ and send all others elsewhere.

4. Low-acuity patients crowd the ED and shouldn’t be there.

5. We can save money by decreasing low acuity ED visits.

Myth Busting

1. Patients attend the ED for access, not because they are stupid.  Most patients don’t need education.

2. Patients come to harm if sent elsewhere. (JAMA)

3. Low-acuity patients do NOT crowd the ED.  They cycle through quickly.  Sick, admitted patients crowd the ED.

4. Marginal costs for minor patient complaints are minuscule:  pennies compared to the cost of keeping the ED open.

High Acuity

‘True-emergencies’ don’t trickle in one at a time.

‘True-emergencies’ often present in batches.  In larger EDs, three critically ill patients often present at the same time, and most providers can recall a time when 4 critically ill patients showed up within minutes.  Each critically ill patient requires up to 4 nurses, a physician, a respiratory technician, and more.

ED Efficiency Killer

Why do governments close low-volume EDs even if they have money to keep them open?

Small EDs often have many hours when they see very few patients.  An acute care resource running at anything less than full capacity wastes money.  Idleness equals waste; it kills efficiency.  

ED Efficiency Solution

Consider a trauma room. Most hospitals keep one or more operating rooms open (staffed), at great cost, to manage trauma or emergency surgery.  Idle trauma rooms are expensive. Hospitals can recover some cost by managing non-emergent cases, especially if the team has already been called in and a suitable admitted patient awaits surgery.

Eliminate idleness to increase ED efficiency.

Hospitals recover cost and gain efficiency by using the trauma room for less urgent, non-trauma patients!

Even IF there was a way to figure out which patients were ‘true emergencies’, EDs large enough to manage all the ‘true emergencies’ in a community would stand idle much of the time at HUGE cost.

EDs recover cost and gain efficiency by seeing less-acute patients.

Mythical ‘High Acuity’ EDs never match the efficiency of a high volume ED. 

How do you approach efficiency in your ED?  How would you deal with ED idleness if you could identify and safely send away all the non-true-emergencies?

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87 Ways to Block Patient Flow Improvements

Blond Boy CryingChange stretches us.

Even good change – getting married, having a baby, retiring – is tough.

In our department, we’ve had a ton of change to improve patient flow, and we’ve heard a ton of complaints.

Here’s a few:

  1. You’re moving too fast.
  2. You’re moving too slow.
  3. What’s taking you so long to get moving?
  4. I wasn’t at the meeting.
  5. I wasn’t invited to the meeting.
  6. You had the meeting without me!
  7. You have too many meetings.
  8. I’m tired of going to so many meetings.
  9. No one asked for my opinion.
  10. You already asked for my opinion.
  11. You should talk with those of us who do the real work.
  12. You shouldn’t listen to whiners from the front line.
  13. You should consult outside experts.
  14. We don’t need experts telling us how to do our job.
  15. You’re too idealistic.
  16. You’ve lost your ideals.
  17. You can’t see the big issues.
  18. You can’t see the details.
  19. Why improve what’s  already better than most?
  20. This place has gone to hell.
  21. But look what we stand to lose!
  22. You have too many details unanswered.
  23. Your proposal is too detailed.
  24. It’s too complicated.
  25. It’s too simple.
  26. It will never work here.
  27. It’s never worked anywhere else.
  28. It takes too much time.
  29. I have nothing to do now.
  30. I’m underutilized.
  31. It takes too much energy.
  32. What are you not telling us?
  33. Your emails are too long; you tell us too much.
  34. You don’t expect us to believe that’s why you’re doing this, do you?
  35. Your data is biased/skewed.
  36. You collect the wrong data.
  37. Your data is anecdotal.
  38. Let me tell you a story I heard…
  39. You should work more clinically; you spend all your time in the office.
  40. You work too much clinically; you should spend more time in the office.
  41. This seems to be all about special treatment for XX providers.
  42. What’s wrong with special treatment for YY providers?
  43. Why should we treat patients as family?
  44. Just because I get special treatment for my family doesn’t mean other patients should get it too.
  45. We might miss one sick patient.
  46. These patients aren’t sick; they should wait.
  47. These patients could all be seen in a walk-in clinic.
  48. These patients need a nurse, a full set of vitals, an ECG, and an acute bed STAT.
  49. One bad outcome is enough to stay the way we were.
  50. It costs too much.
  51. This would work if we spent more.
  52. You are asking us to do someone else’s work.
  53. Someone else is stealing my work; I’m going to submit a union grievance.
  54. There’s no infection control.
  55. We don’t need to see infectious patients so quickly; they can wait.
  56. It’s too stuffy.
  57. It’s too breezy.
  58. There’s too much paperwork.
  59. There’s no paper for notes.
  60. There’s no privacy.
  61. I need more people around to feel safe.
  62. There are too many people.
  63. We need more nurses/doctors/patients/support in the same space.
  64. I feel disconnected from other staff.
  65. I don’t like working shoulder to shoulder with other staff.
  66. It feels like you aren’t supporting the team.
  67. It seems like you only support the X team.
  68. You’re dividing the X team.
  69. I’ve done this for decades.  I don’t need to change a thing.
  70. Those new guys are out of date.
  71. It’s the wrong focus.
  72. You just want to be famous.
  73. Why don’t you spend time on what really matters?
  74. You are out of touch.
  75. You sound like a corporate pawn.
  76. All you care about is X metric.
  77. You just want to undermine Y group of workers.
  78. This sounds like what failed last time.
  79. Are you saying we aren’t working hard enough?
  80. You don’t know what you’re talking about.
  81. If you just changed X, you wouldn’t  need to do this.
  82. You know, this will never work.
  83. We need to give more power to the people actually doing the work.
  84. This is embarrassing.
  85. I used to be proud of working here.
  86. I wouldn’t send my family here; I’d send them to the terrible hospital down the road.
  87. Why can’t you admit this is a stupid idea?

Kotter discussed many of these in  “Buy In”.  He suggests that there are 4 main attacks:

  1. Fear Mongering
  2. Death by Delay
  3. Confusion
  4. Ridicule/Character Assassination

Kotter proposes the following response:

  1. Invite attacks
  2. Respond with clear, simple common sense
  3. Respect always; never fight
  4. Focus on the audience
  5. Prepare for attacks

Change cannot be blocked.  Leadership is change.  Time changes things even if leadership will not.  Patients have benefited from disruptive innovations in our ED, and our whole team proudly wears the scars we earned through it.

How have you responded to change?  Does this list sound familiar?  Click Leave a Reply or # of Replies below.

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Patients Should Complain More – Here’s Why And How To Do It Well

Frustrated Businesswoman on the PhonePatients need to complain more.  Seriously.  But, they should learn how.

Someone shared this last week:

I was lying in urine in the ICU.

My nurse said, “How could you do this?”

I couldn’t help it; I felt so bad.

She was so upset.

I wanted to find out her name, but I’m over it.

She didn’t know.

What will happen to her next patient who wets himself?

Doctors, nurses, clerks, security guards, students…everyone in healthcare provides less-than-excellent care some of the time.  Your complaint can change the system, but you must do it right.

Many confuse complaining with venting like the photo above.

Venting changes:

1. How you feel.

Ha! I sure told him!  You shoulda seen his face…

2. The opinion your listener has of you.

Oh my, she really has issues!

He’s got a point, but he needs to get over it.

Vent a little to those who love you unconditionally.  Put most of your energy into crafting a great complaint.

Here’s how:

Be specific – focus on one issue with objective, gritty detail.

Be polite – rudeness discredits you.   Your main audience is other providers who will subconsciously be questioning themselves, “Would I have treated this person the same way?”

Be dispassionate – be calm; no emotion; not in the heat of the moment.

Be honest and humble – admit your part in the issue, if any.

Offer solutions – know what you want to see changed and how it might be done.

Address your complaint to someone who can make a difference – do NOT vent to a provider in the moment.  It won’t accomplish what you want and could make things worse.

Don’t retaliate – great complaints display genuine desire to improve things.  Complaints that start with the CEO, Chief of Staff, Member of Parliament, or regulatory college won’t get the change you are after.

Bonus points:

Apply your case to others.  Think beyond yourself.

Address system issues.

Huge hospitals completely change policy for one well written complaint.  Learn how to complain well, and you will see the change you hoped for.

Please share your thoughts by clicking on Leave a Reply or # Replies

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Improve Your Trip to Emergency

Patient Filling in a Form

Every dreads a trip to emergency. Here’s how to improve your chance of a great ED visit.

1. Avoid busy times – Never go on Monday, the first day after a long weekend, and Sunday evenings, if possible.  ED visits surge from 11:00 am until late evening.  It takes another 3-6 hours for an ED to clear out.  Aim for early morning or after midnight. Even the worst ED provides great service some of the time; make sure you arrive at those times.

 2. Prepare your chief complaint – Do you tell your whole life story at a job interview?  Don’t tell it in the ED.  Summarize your concern in a few sentences.

 “My stomach started to hurt after supper. It became sharp and constant overnight, and now I have a fever.  It really hurts when I push right here.”

What would you ask if your child had a ‘tummy ache’?

Where does it hurt?

When did it start?

What does it feel like?

Did you get hurt? etc.

If it’s too long to memorize, it’s usually too detailed. If you were just discharged from hospital, say that first.  Hopefully, you got a discharge instruction sheet.

3. Prepare your past medical history – Practice listing your diagnoses.

“High blood pressure, high cholesterol, borderline diabetes and mild asthma.”

If you had major surgery in the last 6 months, say so.  “I had a kidney transplant in May.”

4. Know your medications and dosages – Memorize or write them down on a wallet card. “The little white pill,” does not help.

5. Memorize true allergies and reactions – Swollen lips with penicillin needs to be told.  Find out from your family physician which things you react to, if you don’t know.

6. Bring your Health Card (Canada) – Cards expire.  Update it, if you change address.  If your card is invalid, you will be billed by your physician(s) and separately by the hospital.

7. Bonus points – Old ECGs, notes from your doctor(s) or hospital, X-Ray reports, descriptions of rare medical conditions…anything special about you.

Things to do after you’ve been seen, but are still in the ED:

1. Call for help if you or your family/friend gets worse.  Many patients get worse.  Speak up!

2. Minimize questions.  Staff should have told you how long things will take.  If not, ask once.  Let staff work; wait until they said everything should be done (4 hours, etc).  Do not ask “Are my tests back?” “When is the doctor coming?” “Where is the coffee shop?” etc.

3. Stay in your care area.  Hovering at the doorway is dangerous, impolite and does not make things move more quickly.

4. Don’t take your anger or frustration out on staff.  If they are rude, by all means write a letter.  That will do more than getting upset at the moment, and it strengthens your feedback to leadership.

Things you can do after you’ve left the ED:

1. Call your Family Physician and deliver lab and X-Ray reports from your ED visit.

2. Let your family/friends know you were sick, so they can help and be there if you get worse.

How can you tell if you’re not an average patient?

A.  You are on chemotherapy, have had an organ transplant, have an extremely rare condition cared for by sub-specialists in another center, are on a study drug, have more than 5 medical conditions, etc.  Most complicated patients know they’re not average, and are professionals at navigating the healthcare system.

Patients improve the performance of even the best teams using the pointers above.   Share your favorite tips for a visit to the ED by clicking on Leave a Reply or # Replies below.

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The Secret of Outstanding Clinical Team Performance

How do teams recover when they’re down?

Soccer Player Dribbling Between Defenders

They can’t call in new players.

They can’t increase the number of players on the field.

They can’t quit and go home.

How do they make the best of a losing situation?


Leadership + ‘Coaching with Teeth’

When losers say, “We’ll never win!”  Leaders respond with, “We can do this!  We’ve beat this team before!

Leaders speak up.  They control the tone on the field.

But what if players drown out positive messages by screaming, “We’ll lose!

Coaching with Teeth

At some point, a coach owns the outcome.  If leadership on the side-lines allows the wrong team on the field, we hold them responsible for the outcome.

Library shelves sag with books on how to inspire teams to peak performance; how to recruit the best in everyone.

Sports teams know the answer:

Wrong attitude?  No playing time.

How do you handle this at work?

Who decides which team is on the field in hospitals?

Who decides who gets to play?

Is it even possible to keep certain players off the field?

How do we promote the best?

How do we keep our best players in the game?

Performance Management

We hire staff based on clinical competence, and we manage it on our teams.

We hire staff based on their attitude, but do we manage attitude?

If you steal medications, you get fired.  If you bully, you get fired.  But, no one gets fired for a bad attitude.  You will never lose your job for saying, “We’re going to lose!”

Clinical competence is necessary, but NOT sufficient for outstanding performance.  Without a great attitude, your clinical team will never shine.

Attitude must be a key measure in performance management.

What do you think?  Click Leave a Reply or # Replies to comment.

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See How Patient Flow Improved: Mini-Trial of RN-MD Triage

Early Success!


We tried a nurse-physician team with 3 stretchers in our old (empty) waiting room.  We did not change our old process; just added a parallel process out front.

An RN met all ambulatory arrivals at the front door for a quick look as before (pre-triage).  Ambulance patients came in through a separate process.  We ran the parallel RN-MD trial from 10:00 – 13:00.


Patient arrives to see an RN screener/sorter/pre-triage.

Patient directed to an RN-MD team with 3 beds in the waiting room.

Patient sent to registration.

Patient sent home or to appropriate clinical area.

If RN-MD process overwhelmed, patient sent to traditional triage.

At any point, patient sent to acute room as indicated.

Results for 3 hour trial:

30 ambulatory patients seen (less than average volumes?)

Time to see MD = 0 minutes for 27 patients (< 3 minutes from RN screener).

3 patients direct to acute room by RN screener.

5 patients (17%) seen and discharged home by the MD-RN team

3 exam spots added (6% additional capacity) at ZERO cost.

0 left without being seen

0 patients required traditional triage


We identified a number of things to improve for our relaunch next week.

Staff who had strongly opposed the trial turned optimistic.

As a team, we had become overly anxious to try new things after a major change ‘failed’ in 2012 (we tried something for 2 1/2 days that didn’t work as hoped).  We got a boost today.

We’ll share process detail and performance data as we gain more experience.

Have you tried something like this?  Share your thoughts by clicking on Leave a Reply or # replies below.

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See What We’re Trying Next to Improve ED Patient Satisfaction, Quality and Flow

So far, we’ve posted what works.  In two days, we will try something that (almost) never works.



Does repeated failure mean something is impossible?


Hundreds of teams of really smart people have failed to improve outcomes and efficiency by putting physicians at triage.   In some cases, flow did not change.  In others, costs were too high.  We want to try it anyways.



Why would we bother?


It’s what we want for our families.  

When nurses and physicians need a medical opinion, they go straight to the nearest MD they trust.  Direct access.  All the non-value added steps removed.

Time equals quality in emergency medicine.  

The sooner we diagnose and treat patients, the higher quality of care we can guarantee.


The chance to radically improve flow and efficiency is just too attractive to ignore.  Imagine being able to see and treat even 10% of your patients out front – a chunk of patients would never enter the ED.  30 fewer patients and family members packed into the bowels of the ED seems reason enough to try it.

Fewer steps = lower cost.  

If we could exam and begin treatment without a lengthy pre-screen, triage and registration process, we would decrease the number of providers involved and decrease patient length of stay.  Staffing costs and length of stay directly impact efficiency.

Parallel processing beats sequential processing.  

Modern ED Triage is sequential.  It’s guaranteed to become a bottleneck unless an oversupply of staff continually support it.  A parallel RN-MD clinical stream right at the front door seems destined to succeed.


“If it ain’t broke…”  

We’ve ranked with the top 3 EDs in Ontario for time to physician initial assessment (PIA) for 18 months.  Our average PIA hovers just under 1 hour.  However, Voltaire said, “The good is enemy of the best” (approximately).  Unless we continually improve, we will slip back.

Everyone failed – why won’t you?  

Failed attempts don’t mean something is impossible.  As Thomas Edison said, “I have not failed.  I’ve just found 10,000 ways that won’t work.”  If a concept seems logical and irresistible, it’s worth trying again.  Also, St. Joe’s Hamilton seems to enjoy early success with their recent attempt at putting a physician at triage which inspires us to try it for ourselves.

We’ll let you know how it turns out when we try it in 48 hrs.  Please share your thoughts below – tell us what we need to know.  There’s still time to change what we’re about to attempt!

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Emegency Departments That Lag

Time to treatment equals quality for much of emergency medicine.  It’s also the easiest way to decide whether an ED is any good.  Missed diagnoses, errors of judgment, and clinical mistakes can be hard to spot by comparison.

Emergency Departments That Lag

1.  Long Line up at triage –

The most at-risk patients stand in the line-up for triage.  Every day, patients walk in with a deadly process inside of them.  Until they have been seen, they are unsafe.  A line up to be seen is indefensible.

2.  Long triage process –

Triage should be sorting; not a primary nursing assessment.  Patients need a diagnosis and treatment.  In most cases, this means getting patients and physicians together as fast as possible.  A long triage process does not add value for patients.

3.  Long Line up at registration and long registration process –

Registration – getting a chart made – does not add value for patients; it only delays care.  It must be short!

4.  Packed waiting room –

There is no reason for patients to EVER wait in the waiting room.  Please argue in the comment section below if you disagree.

5.  Patients must repeat their story over and over and over.

Providers should quickly check what others have recorded, verify the facts and ask additional questions.  Starting over with every provider drives patients nuts.

6.  No discharge excellence

Patients should leave the ED with copies of lab and radiology reports, written discharge instructions (if necessary), and clear instructions for follow-up and return visits to the ED.

7.  Dismissive attitude

Patients should be welcomed to the ED for ANY complaint.  No complaint is trivial for a patient.  We – healthcare providers, media, government, all of society – seem to think healthcare would be just fine if it weren’t for all the patients.  Besides being unwelcoming non-verbally, there’s a big difference between “Why are you hear today?” and “How can I help you?”

Rules in case you get sick:

Don’t go to your family doc unless you’ve tried something yourself first.

Don’t go to your specialist unless you go to your family doc first.

Don’t go to the ED unless you’ve gone anywhere else first.

Don’t go to the ED unless you are nearly dying.

If you are dying, you shouldn’t go to the ED because we can’t do anything for you…



But all our beds are full of admitted patients!

Definitely the most popular excuse, admitted patients definitely make it almost impossible to provide emergency care some of the time.  But, even with admitted patients blocking beds, patients should still be brought into the ED and seen on exam tables.  If they can wait on chairs in the waiting room, they can wait on chairs inside after they’ve been assessed.

Thankfully, Ontario has started to hold hospitals accountable for getting admitted patients out of the ED, and up to the wards.

Who owns morale?

Management owns operations; staff owns morale.  Sure, you can crush morale in even the most engaged staff, but blaming management for staff attitudes will mire an ED in under-performance.  Staff control their own morale, and it must be part of performance management.

How does your ED stack up?  As a patient, have you researched your local EDs to see which ones to avoid?  

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What You Need to Know to Improve Patient Flow at Triage

Modern triage = patient sorting + a boat-load of protocols and ‘value added’ steps.

Napoleon’s surgeon seems to be the first provider to try a sorting process for crowds of patients.  He wanted to quickly sort which wounded soldiers were most likely to return to battle, so he could provide care for them first.  Historical triage got soldiers back into action while seriously wounded soldiers were left to die.


In the olden days of emergency medicine (30 years ago), patients could usually be seen soon after registration.  They were brought straight in, seen by a nurse and a physician soon after.  In the 1990s in Ontario, the ED became a favourite spot to park admitted patients when the inpatient wards became ‘full’ as defined by staff working on the wards.

Around this time, triage turned into primary care nursing for new arrivals and the crowd of patients warehoused in the waiting room.

This was never meant to be.

Triage must be rapid sorting or it’s not triage at all.

Long interviews, multiple forms, medication reconciliation, past medical history, allergy lists, infection control screening, extensive sets of vital signs, patient examination, wound inspection, and answering questions about waits, parking, directions and vending machine locations – modern triage redefined the term ‘triage’.

Maybe that’s a good thing?  Surely, all the added work being done by modern triage was started for a reason?  Maybe patients want to come to the ED to get a really thorough triage?


Patients come to the ED to get a diagnosis and treatment.  Anything that stands in the way of diagnosis and treatment does not add value for patients.

Triage should add value by getting patients to the care they need as quickly as possible.  We should resist anything that stands in the way of patient care.  Quality care depends on timely assessment and treatment.  Triage adds value only if it facilitates timely care.  Triage should never bottleneck flow; there should never be a line-up to see the triage nurse.

We must unload all the duties we’ve piled onto triage, if we are serious about improving patient flow.

If hospitals insist on running waiting rooms like a clinical areas, patients would be better served by assigning nurses to care for the patients in the waiting room instead of shackling triage nurses with non-value-added work.

Does triage add value in your hospital or does it delay care?  Is there a patient line-up for triage?  

Please click Leave a Reply or # replies below.

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