Author: Shawn Whatley

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.

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?

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.