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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Revamp Triage to Decrease Waits

Blue YetiSome people do not have time to read books. But they listen to podcasts.

So, I plan to give away as much of the content in No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments as I can squeeze into podcasts and short blogs.

The first podcast covers the Introduction and first chapter: Step 1 – Revamp Triage. This blog gives a snapshot and overlaps the podcast. I hope it gets people talking about the ideas, even if they do not have time to read the book.

Here’s the first podcast (I had fun making it!):

Introduction

Doctors, nurses, allied health providers, administrators make patients wait. We blame problems outside our department or clinic. But if we wait for outside help, nothing will improve.

We need to change how we work, first. We have to tackle misaligned incentives, arcane policies, and draconian legislation to do what is right for our patients. We need relentless devotion to improving patient service and care. Even if we only make small improvements, we will have much more credibility when we ask for bigger, system-level, changes.

NMLW uses old ideas. It does not describe a new fad or secret recipe to reform healthcare. We need a new perspective, not another wunder-plan that promises to fix everything.

The ideas in NMLW work together. You cannot close your waiting room without changing nursing ratios, doctors’ schedules, and furniture inside the ED.

If you give these ideas an honest try, you can expect that patients will:

  • Not wait in the waiting room
  • Be seen by an MD in < 1 hour
  • Have the shortest possible length of stay
  • Receive the highest quality care and service

Be careful, political responsibility, or system guilt, will ruin your best efforts to improve patient service. We need to put aside our angst about costs, the broader system, and spending for a moment. Only a relentless devotion to patient service will improve ED function.

Devotion to patient service drives down costs per case, length of stay, adverse events, and, in fact, everything in an ED functions better when we focus on patients first, and the broader system benefits for it. But do not start with system guilt; start with patients first.

Revamp Triage

Patient go the ED to get a diagnosis and treatment in the shortest time possible. They have no chance of getting what they need, while sitting in a waiting room.

Triage has become such a part of emergency medicine that we believe every patient deserves a good thorough triaging. Even with doctors and nurses standing ready to see patients, we still force patients through a fulsome triage.

Napoleon’s surgeon invented triage as the army ran out of soldiers. He needed a way to pick out wounded infantry that could be patched up and sent back into battle as quickly as possible.

We invented modern triage as our system started running out of money. Cash-strapped hospitals use EDs as an extra ward, and waiting rooms as overflow. Triage is designed to manage the crowds.

The Canadian Association of Emergency Physicians states that triage, in its simplest terms, is sorting or prioritizing. There has always been some kind of triage, long before modern triage existed. ED registration clerks working alone, out front, on overnight shifts, used to bring in patients who looked too sick to register.

Today, formal triage includes collecting a chief complaint, acuity score, and deciding on the best location for a patient to go. But it also includes a history, screening for influenza-like-illness, a focussed physical, past medical history, medication reconciliation, and a whole bunch of other duties. Large hospitals often employ 4 triage nurses to manage packed departments.

Patients just want a diagnosis and treatment as efficiently as possible. They do not go to the ED to endure processes of questionable benefit. Triage needs to change.

Patient Flow

Most of the time, providers inhibit patient flow. We batch tasks, work inefficiently, or we just get overwhelmed and slow down. Decreased patient flow causes increased length of stay which results in increased workload. There is no excuse for people doing “a really good job” by spending 45 minutes educating one patient, while everyone else waits for care.

At the same time, we cannot confuse great flow with cutting corners, going really fast, and providing inadequate, low quality service and care. We need to do fast things fast and slow things slow.

The Institute for Clinical Evaluative Sciences outlined quality indicators for emergency care. They found evidence for 48 indicators: 23 are related to time, and 16 are entirely time-based, e.g., time to antibiotics, time to ECG, or time to thrombolysis.

For emergency care, time equals quality. In other settings, “quality” balances effective, safe, patient-centred, timely, efficient, and equitable care. But the ED is different.

No matter how ‘great’ care you provide when patients finally receive it, if you make patients wait for hours, by definition, you deliver low quality care.

Historic Triage

We need to triage patients IN to the department and not back OUT to the waiting room. A skilled nurse can collect a chief complaint, assign an acuity score, and decide on the best location for a patient in 1-2 minutes. The rest of of the triage nurses can work inside the department providing care.

That leads us to the next chapter: Step 2 – Close the Waiting Room.

I hope you get a chance to discuss these ideas with your colleagues. If you have comments, comments and suggestions, leave them below or email me, so we can discuss them in the next blog / podcast. Thank you!

photo credit: Blue Microphones Yeti USB Microphone, Blackout on Amazon.ca

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Politics and Wait Times (podcast)

Shawn and Jason 2016Dr. Jason Profetto made me squirm with tough questions on his podcast. Please let me know if I said anything crazy.

We discussed politics and wait times…even rectal exams.

This interview offers a great introduction to the content of No More Lethal Waits.

Episode 14: A Chat with Shawn Whatley

Jason asked what one thing needs to change to fix wait times. He tried to pin me down. Who makes a bigger impact: Concerned Ontario Doctors or the Ontario Medical Association?

He did a great job. I hope you enjoy the exchange!

 

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