Emegency Departments That Lag

Time to treatment equals quality for much of emergency medicine.  It’s also the easiest way to decide whether an ED is any good.  Missed diagnoses, errors of judgment, and clinical mistakes can be hard to spot by comparison.

Emergency Departments That Lag

1.  Long Line up at triage –

The most at-risk patients stand in the line-up for triage.  Every day, patients walk in with a deadly process inside of them.  Until they have been seen, they are unsafe.  A line up to be seen is indefensible.

2.  Long triage process –

Triage should be sorting; not a primary nursing assessment.  Patients need a diagnosis and treatment.  In most cases, this means getting patients and physicians together as fast as possible.  A long triage process does not add value for patients.

3.  Long Line up at registration and long registration process –

Registration – getting a chart made – does not add value for patients; it only delays care.  It must be short!

4.  Packed waiting room –

There is no reason for patients to EVER wait in the waiting room.  Please argue in the comment section below if you disagree.

5.  Patients must repeat their story over and over and over.

Providers should quickly check what others have recorded, verify the facts and ask additional questions.  Starting over with every provider drives patients nuts.

6.  No discharge excellence

Patients should leave the ED with copies of lab and radiology reports, written discharge instructions (if necessary), and clear instructions for follow-up and return visits to the ED.

7.  Dismissive attitude

Patients should be welcomed to the ED for ANY complaint.  No complaint is trivial for a patient.  We – healthcare providers, media, government, all of society – seem to think healthcare would be just fine if it weren’t for all the patients.  Besides being unwelcoming non-verbally, there’s a big difference between “Why are you hear today?” and “How can I help you?”

Rules in case you get sick:

Don’t go to your family doc unless you’ve tried something yourself first.

Don’t go to your specialist unless you go to your family doc first.

Don’t go to the ED unless you’ve gone anywhere else first.

Don’t go to the ED unless you are nearly dying.

If you are dying, you shouldn’t go to the ED because we can’t do anything for you…

 

Excuses

But all our beds are full of admitted patients!

Definitely the most popular excuse, admitted patients definitely make it almost impossible to provide emergency care some of the time.  But, even with admitted patients blocking beds, patients should still be brought into the ED and seen on exam tables.  If they can wait on chairs in the waiting room, they can wait on chairs inside after they’ve been assessed.

Thankfully, Ontario has started to hold hospitals accountable for getting admitted patients out of the ED, and up to the wards.

Who owns morale?

Management owns operations; staff owns morale.  Sure, you can crush morale in even the most engaged staff, but blaming management for staff attitudes will mire an ED in under-performance.  Staff control their own morale, and it must be part of performance management.

How does your ED stack up?  As a patient, have you researched your local EDs to see which ones to avoid?  

What You Need to Know to Improve Patient Flow at Triage

Modern triage = patient sorting + a boat-load of protocols and ‘value added’ steps.

Napoleon’s surgeon seems to be the first provider to try a sorting process for crowds of patients.  He wanted to quickly sort which wounded soldiers were most likely to return to battle, so he could provide care for them first.  Historical triage got soldiers back into action while seriously wounded soldiers were left to die.

Nice.

In the olden days of emergency medicine (30 years ago), patients could usually be seen soon after registration.  They were brought straight in, seen by a nurse and a physician soon after.  In the 1990s in Ontario, the ED became a favourite spot to park admitted patients when the inpatient wards became ‘full’ as defined by staff working on the wards.

Around this time, triage turned into primary care nursing for new arrivals and the crowd of patients warehoused in the waiting room.

This was never meant to be.

Triage must be rapid sorting or it’s not triage at all.

Long interviews, multiple forms, medication reconciliation, past medical history, allergy lists, infection control screening, extensive sets of vital signs, patient examination, wound inspection, and answering questions about waits, parking, directions and vending machine locations – modern triage redefined the term ‘triage’.

Maybe that’s a good thing?  Surely, all the added work being done by modern triage was started for a reason?  Maybe patients want to come to the ED to get a really thorough triage?

NO!

Patients come to the ED to get a diagnosis and treatment.  Anything that stands in the way of diagnosis and treatment does not add value for patients.

Triage should add value by getting patients to the care they need as quickly as possible.  We should resist anything that stands in the way of patient care.  Quality care depends on timely assessment and treatment.  Triage adds value only if it facilitates timely care.  Triage should never bottleneck flow; there should never be a line-up to see the triage nurse.

We must unload all the duties we’ve piled onto triage, if we are serious about improving patient flow.

If hospitals insist on running waiting rooms like a clinical areas, patients would be better served by assigning nurses to care for the patients in the waiting room instead of shackling triage nurses with non-value-added work.

Does triage add value in your hospital or does it delay care?  Is there a patient line-up for triage?  

Please click Leave a Reply or # replies below.

The Secret of Great Hospital Performance

MP900386070When you pull out to pass a car on the highway, what do you care about?
Do you care about speed or…
do you care about your gas pedal? 
We press on the gas pedal (input) in order to pass (output).
We focus on the job at hand, what we need to get done. We do not care about the gas pedal. We care about passing safely.

Healthcare focuses on the gas pedal.

  • How much will this cost?
  • How big is our budget deficit?
  • Where can we trim costs?
  • Why are costs going up so fast?

It’s understandable. Money grabs our time and attention in hospital leadership.  But, like the gas pedal, inputs should be secondary. Our biggest concern should be outputs, are we delivering great care?

Block funding for hospitals died years ago in most countries.  Unfortunately, block funding still thrives in many Canadian hospitals.

Block funding = stretch one pile of cash out for a whole year of hospital services.

  • No funding for growth.
  • No funding for acuity.
  • No incentives to deliver more care.
  • Focus on the budget; don’t spend a penny more…keep the gas pedal in focus.

Fortunately, most jurisdictions are starting to admit that block funding doesn’t make sense.

Focus on Outputs

The secret to great hospital performance = focus on outputs.  Focus on great service and outcomes for patients, first.