Reservoirs Kill Patient Flow

Reservoirs often show up as extra capacity, and who wouldn’t welcome that? Shiny new clinical space gets first place on hospital tours, center stage in photo shoots and prominent mention in ad covers.

We find reservoirs all over healthcare: special inpatient wards, waiting rooms, bigger clinics, bigger emergency departments…extra capacity.

But, mindlessly expanding capacity decreases patient flow – increases patient waiting – if we don’t guard against forming reservoirs.

5 features of reservoirs in healthcare:

1. Reservoirs slow patient flow. Like giant, hydro-electric dams, they convert high flow, hard-to-manage situations into low flow, contained events.

2. Reservoirs allow us to meter out patients – for example,
we trickle them in from the waiting room into the ED, or trickle them up to the inpatient wards – when we are ready to see them.

3. We find reservoirs familiar; a common solution to high flow demands. They’re socially acceptable. In fact, most institutions pride themselves on the size of their reservoirs.

4. Reservoirs decrease chaos and make us feel safe, but patients feel just as scared and unsafe while parked in a reservoir.

5. Reservoirs fill easily. They attract contents. Reservoirs might empty now and then, but they tend to promote filling and storage (waiting).

Waiting rooms, gigantic emergency departments or even special inpatient wards are reservoirs, and patients do not benefit from them if they exist only to slow patient flow.

These fat areas in the stream of patient flow end up grinding flow to a halt without extreme vigilance to keep patients moving.

We have to match patient volumes with flow; not capacity. Sure, we always need more beds, but we need increased flow more. Flow doesn’t just mean flow out of the hospital; it means flow in, too. We often blame long term care or families for not taking patients home, as though there’d be no waiting if there were no alternate level of care patients (ALC; patients who need long term care) in the hospital. Or, we blame the inpatient wards for not taking patients out of our EDs sooner.

Truth is: we didn’t have an ALC problem years ago, but we still had admitted patients in the ED. ALC represents one (major) factor impeding flow, but it’s not the only issue.

In the same way, patients crowded ED waiting rooms long before holding admitted patients in the ED became such a problem.

Until we develop a culture of taking every patient in – in to the ED and up to the wards – when they present, and not just when we are ready for them, we will never get rid of reservoirs and crush patient waiting.

How can we balance maximal patient flow and institutional capacity? Is bigger better? How can we avoid building reservoirs?

Why build waiting rooms? For patients or providers?

Every emergency department has a waiting room that probably gets used more than any other room in the ED.

Did a patient group meet and declare they wanted waiting rooms?

Of course not. Patients come to the ED to get help; not sit in a waiting room.

“Well, patients need to be able to wait somewhere before they get inside the ED.”

Why?

Why can’t we bring all the patients straight inside the ED?

Sigh.

Only someone painfully unaware of modern ED struggles could ask such a silly question.

“We don’t bring patients inside the ED because we don’t have enough resources to care for them.”

It’s all about stretchers and ratios. We decide the ED is full when all our stretchers are full. We decide the number of stretchers by how many nurses we have working based on a ratio of 4 stretchers to 1 nurse.

Stretchers and ratios keep everything neat and orderly inside the ED.

So, to maintain order inside the ED, we build waiting rooms to house all the patients that we don’t feel ready or able to help. No matter how many patients pile up in the waiting room, we stick to our stretchers and ratios.

Providers want waiting rooms; waiting rooms benefit providers not patients. Patients want to come straight inside the ED.

Why don’t we bring all patients inside? What could be worse for patients than leaving them for hours in the waiting room?

Waiting harms patients – A novel idea?

A room full of unbelieving faces stared back at me. I had just finished presenting a brief review of the negative clinical impacts of patient waiting.

They didn’t buy it. My medical colleagues flatly rejected overwhelming evidence.

Why?

It’s been said that every idea must pass through 4 stages:

1. Critics scoff at your new idea because it’s novel and lacks supporting data.

2. After gathering data, critics say it lacks significance or is biased.

3. Eventually, your idea catches public interest. It gains popular support.

4. Finally, everyone accepts your idea, and the critics tell how your idea was theirs from the start.

Despite hundreds of papers clearly demonstrating harm for patients due to waiting, we will never see improvement without popular support.

We need to engage the public – educate them – on the risks to their health when they wait in crowded emergency departments. We need hospital leaders and governments to understand that waiting harms patients.

We need to challenge our cherished clinical processes that have been designed to benefit providers, but actually add harmful waiting to patients’ experiences.

We need to share solutions – brave innovations – that strip all the useless, harmful waiting out of our patients’ time in our institutions.

At which stage are you in realizing that waiting harms patients? What needs to be done to recruit you, and others, as champions to help STOP Patient Waiting?