Patient Flow into Buckets or Patient Flow into a Funnel?

bucketsNurses and doctors think patients belong in buckets.

Not literal buckets; buckets of care: primary care bucket, emergency medicine bucket, inpatient bucket…

How do we know providers believe in a bucket concept of care?

They tell patients they’re in the wrong bucket!

They tell patients to get out of the bucket!

They tell patients to go to a different bucket next time they need care.

Hilton hotels suggests staff should be empowered to handle ANY issue that arises for guests during their stay.

What happens in healthcare?

Sorry, ma’am.  You’ll have to go somewhere else for that.

Sorry, sir.  I don’t have time to discuss that with you.  The ED isn’t the place for that kind of problem.

Subtitle:  And don’t come back next time!

Funnel of Care

Patients should seek care where THEY choose.  How they choose and how we can help them make a great choice will be discussed in another post.  For now, once patients present with a concern – no matter where they present – we should be prepared to help to whatever extent we can.  Sending them away with a dismissive, “This isn’t an emergency” is unacceptable.

The funnel starts where patients choose to access care.  The funnel continues to more and more specialized care until patients get what they need.

With bucket-thinking, we expect patients to make their own clinical judgment.  Then, we berate them for poor clinical judgment:

“Why didn’t you go see the family-doc/walk-in-clinic/anywhere-else?”

But without clear, available access, patients are forced to attend the ED.  EDs refer patients to their family docs for follow-up far more than family doctors refer to the ED.  Referral patterns have reversed.  We could make the ED a referral only facility like an ICU – no entry without a referral letter.  Family Docs and clinics would need advanced access, longer office hours, basic resuscitation equipment…

System issues force patients to seek care wherever they can get it.  It’s our job to help them when they get there; not send them away.

What do you think?  Would you want your family to be sent away from the ED?  Is that safe?  Is it good customer service?  Click Leave a Reply or # of Replies below.

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?