ED Stretchers Boarding & Flow

Racing a patient through the emergency department on a stretcher makes exciting TV.

But for most EDs, stretchers are the enemy, because stretchers crush patient flow.

Most patients walk into the emerg and walk home – less than 15% get admitted in Canada. There’s no need to force patients to lie on a stretcher unless absolutely necessary.

Patients sit for hours with serious or potentially life-threatening conditions in most waiting rooms. It’s much safer to get them in and examine them on an exam table inside the ED even if it means they have to sit in chairs during investigation and treatment.

Sure, some patients need stretchers for the duration of their ED visit. But for most patients, if they can walk, they can sit. If they can sit, they do not need a stretcher.

Stretchers enable dysfunctional behaviour that makes patients wait.

Stretchers –

1. Attract admitted patients boarding them for days.

2. Act like real estate for ED patients. Providers assign one ‘lot’ for each patient.

3. Make patients immobile even if they walked into the ED.

4. Allow providers to ‘tuck patients in’, rails up, safe and sound.

Exam tables increase flow by –

1. Removing a spot for admitted patients. Exam tables are like OR tables: OR tables are for surgery, not admission.

2. Providing a shared resource for all, not an assignment for one.

3. Getting patients to move, which fosters flow. Exam tables don’t have wheels.

4. Keeping providers moving with patients. Exam tables are unsafe without a provider present. Patients spend minutes on an exam table instead of hours on a stretcher.

Dozens of patients cycle on and off one exam table, whereas one stretcher serves only a few patients per day. If the average patient spends 6 hours in the ED, each stretcher can serve, at most, up to 4 patients per day and usually far less.

If you haven’t done so already, replace as many stretchers as possible with exam tables. If exam tables are only found in the minor treatment area, you don’t have enough!

Like any change in historic process, providers realize how attached they are to stretchers when you start asking them to use exam tables instead. But without building EDs twice the size, we cannot continue insisting that all patients, except the lowest acuity, get seen on stretchers. Staff support exam tables once they see how much flow improves; it’s the best way to get patients seen and treated promptly in today’s over-crowded EDs.

Stretchers ruin patient flow, function as a reservoir and promote dysfunctional behaviours. Get rid of them where ever you can!

Do admitted patients block your ED stretchers? Do all your ED patients currently in stretchers actually need to be in one? Are they blocking flow making other patients wait for care? Why not replace some stretchers with exam tables?

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?