Category: No More Lethal Waits

If patients can sit in chairs for hours in the waiting room, then they can sit in chairs inside the emergency department.

Only the very sickest patients should get defined care spaces with stretchers.

Over 85% of emergency patients get sent home.  They do not need stretchers. Even some patients who need admission do not need a stretcher.

Keep vertical patients vertical and moving.

Emergency departments will never excel with the wrong furniture.

This post/podcast highlights the key ideas from Step 4 in my book: No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments.

Use Chairs and Exam Tables, Not Stretchers

Stretchers can be numbered. They are finite, ‘safe’, mobile, and locatable. Stretchers foster rigid thinking. They support rigid nurse to patient ratios.

Stretchers attract admitted patients like watermelons produce fruit flies the next day.

Physical exams should occur on exam tables, in private. Patients can sit in chairs with their IVs. They can shuttle off to x-rays, or wait for blood work, from chairs.

You do not need to force patients into stretchers. Even patients with chest pain can spend most of their time in the ED on a chair.

Exam tables

• do not have wheels, so you cannot move patients around on them.
• have paper, not sheets, so physicians can change an exam table quickly without waiting for house cleaning.
• have no sides making it unsafe for patients to stay on them unattended.
• have hard surfaces that make them uncomfortable beyond brief exams.

Admitted patients cannot be admitted on to a exam table.

Exam tables are never full. They are a shared resource, whereas patients ‘own’ their stretcher for the whole ED visit.

Exam tables force patients to get up and move.

Exam tables are like operating room tables. No one ever admits a patient to an operating room table. OR tables are used only when staff are present.

Stretchers attract admitted patients, act like real estate, encourage patients to remain immobile, and allow patients to be tucked in safe and sound.

Emergency departments need exam tables everywhere, not just in the fast track/minor treatment areas.

Mental Furniture

Emergency departments need the right mental furniture.

Inpatient thinking harms patients.

On the wards, delay is good; waiting often helps patients get better.

• Sick patients want extra time.
• It’s compassionate and polite to go slowly.
• Waiting for tomorrow never causes harm.
• Sending people home just creates more work.
• Hasty decisions are often wrong.
• Delay rarely kills a patient after a diagnosis has been made.

But it’s opposite in EM care.

• Delay harms patients.
• Decreased length of stay (sending patients home) decreases work.
• Spending 40 minutes on compassionate care, or counselling, robs clinical services from people waiting for care.

Teams need an attitude of ‘get it done now’.

They need to pursue quality, capacity, and service in a way that fits with an emergency medicine mindset.

We need to be radically committed to service.

Emergency providers are always on, in the spotlight. We need to treat diaper rashes with as much sensitivity as trauma.

Patients determine the validity of a complaint, not providers.

There are no undeserving patients.

If teams are allowed to consider some patient concerns as minor, or a reflection of poor self care, it will poison the attitude required to serve.

We need to lose our arrogance and stoop to help every time.

You will find more in the book, but this gives a sense of Step 4 – Use Chairs and Exam Table, Not Stretchers, in No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments.

photo credit: hamiltonmed.com

Nursing workload revolves around nurse to patient ratios. It makes each nurse responsible for his/her own patients.

Managers cannot ignore ratios and keep their jobs. Ratios drive union grievances.

A great ratio makes a tough nursing assignment manageable. A ward with terrible ratios drives nurses away.

Nurse to patients ratios are sacrosanct to many. But rigid ratios create big problems if a clinical area sees unscheduled visits.

Question: How can you schedule a fixed ratio of patients for every nurse, if an emergency department must see everyone who shows up?

Answer: By making everyone wait in the waiting room to protect rigid nurse to patient ratios inside the ED.

This blog & podcast summarize the key points from Step 3 – Redefine Nurse to Patient Ratios in No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments.

Nurse to Patient Ratios

If 120 patients have registered to your ED, and 12 nurses are working, then the nurse to patient ratio is 1:10. Pretending that the ratio is 1:4 or 1:6 inside the ED puts patients at medical risk in the waiting room. It also puts the hospital at risk of lawsuit should someone die while waiting.

Emergency departments must assume they have unlimited capacity. They must see everyone. Rigid nurse to patient ratios work on inpatient wards, not in the ED. If you Close the Waiting Room and bring everyone inside right after triage, you need to redefine nurse to patient ratios.

Doctors must see and discharge patients to drop nurse to patient ratios from 1:10 down to an ideal of 1:6 or 1:4. EDs need to see patients, treat them, and send them home (or admit them). Pretending patients do no exist, because they sit in the waiting room, puts patients at risk.

Buy In

Nurses work hard caring for patients and many will go far beyond duty to help. But nurses stay alert for managers who might take advantage of them.

How can you get nurses to bend the rules around ratios?

Speak to nurses’ core motivation for caring. Hard work now makes life easier later; it decreases patients’ length of stay (LOS). Reduced LOS improves job satisfaction and decreases the overall work for the nursing team.

Teams that pull together, help each other out, and get patients seen and sent home as promptly as possible end up with the lightest work load overall. And they end up giving patients exactly what they want: a diagnosis and treatment as quickly as possible.

As we run out of money, EDs try to do as little as possible for as many patients as time allows. A poverty mentality creates an ED with no resilience, no ability to respond to a surge in volumes. We need ED teams to take an abundance approach and do as much as they can for every single patient so that when a crisis hits, teams have resilience to respond.

RN concerns

Two nurse managers, 2 nurse coordinators, and an RN educator offered the following comments about No More Lethal Waits ED:

– After a few months, nurses come around and support the new approach. It’s much safer than letting patients wait for hours. But it takes time to get used to it.

– RNs talk about guidelines and their license when you discuss change. They’re often just “covering their butt”.

– Nurses worry that trimming triage = trimming RN positions. Reassure them that triage RNs get redeployed into the ED. We do not cut RNs with this transformation

– Triage is NOT safer

– Nurses have a rule-based culture. Change and innovation are hard.

– RNs often do clerical work because it’s easier

– New grads take a year to train and orient to the ED. In the old days of hospital nursing training, they were ready to go from day 1.

– Partner with your unions!

– Hire well (and fire promptly).

– RNs worry that decreasing the role of triage will decrease the influence of RNs on emergency care

– Sacred cows: triage, RN to patient ratios, culture, and history

– Change: people think they want it but get worked up over “how it used to be”

 

There’s a tonne more in the book, but I hope this gives a sense of the chapter. Please share your thoughts below or email me. Thanks!

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!