See What We’re Trying Next to Improve ED Patient Satisfaction, Quality and Flow

So far, we’ve posted what works. In two days, we will try something that (almost) never works.

Does repeated failure mean something is impossible?

Hundreds of teams of really smart people have failed to improve outcomes and efficiency by putting physicians at triage. In some cases, flow did not change. In others, costs were too high. We want to try it anyways.

Why would we bother?

Pros

It’s what we want for our families.

When nurses and physicians need a medical opinion, they go straight to the nearest MD they trust. Direct access. All the non-value added steps removed.

Time equals quality in emergency medicine.

The sooner we diagnose and treat patients, the higher quality of care we can guarantee.

Irresistible.

The chance to radically improve flow and efficiency is just too attractive to ignore. Imagine being able to see and treat even 10% of your patients out front – a chunk of patients would never enter the ED. 30 fewer patients and family members packed into the bowels of the ED seems reason enough to try it.

Fewer steps = lower cost.

If we could exam and begin treatment without a lengthy pre-screen, triage and registration process, we would decrease the number of providers involved and decrease patient length of stay. Staffing costs and length of stay directly impact efficiency.

Parallel processing beats sequential processing.

Modern ED Triage is sequential. It’s guaranteed to become a bottleneck unless an oversupply of staff continually support it. A parallel RN-MD clinical stream right at the front door seems destined to succeed.

Cons

“If it ain’t broke…”

We’ve ranked with the top 3 EDs in Ontario for time to physician initial assessment (PIA) for 18 months. Our average PIA hovers just under 1 hour. However, Voltaire said, “The good is enemy of the best” (approximately). Unless we continually improve, we will slip back.

Everyone failed – why won’t you?

Failed attempts don’t mean something is impossible. As Thomas Edison said, “I have not failed. I’ve just found 10,000 ways that won’t work.” If a concept seems logical and irresistible, it’s worth trying again. Also, St. Joe’s Hamilton seems to enjoy early success with their recent attempt at putting a physician at triage which inspires us to try it for ourselves.

We’ll let you know how it turns out when we try it in 48 hrs. Please share your thoughts below – tell us what we need to know. There’s still time to change what we’re about to attempt!

7 Common Patient Waits & How to Fix Them

After supper, a friend told me healthcare gave terrible service.

As a senior management consultant for a well-known multi-national corporation, he spends his time helping companies run well. In his opinion, healthcare runs poorly.

While full of wonderful, caring people, healthcare is inconvenient and inefficient.

7 Waits and How to Fix Them

1. Waiting for appointments with Family Practice – All family docs could offer same day visits. Some physicians have been doing it for decades. Their patients love it, and their practices remain profitable. Some patients want appointments booked days in advance and that should continue. Other patients want to be seen the same day and could be accommodated with on-site urgent-care clinics or advanced access booking.

Patients should never have to wait to see their family doc (or a physician in the practice group).

2. Waiting in the waiting room for your physician – This should be very rare. When it happens every visit, it represents terrible practice management. Physicians run 2-3 exam rooms to prevent patient waiting. If physicians are double-booking because of patient no-shows, then they should collect no-show fines or consider firing patients from their practice who continue to not attend for booked appointments. If physicians are booking too many patients to see them promptly, they need to stop booking so heavily and spread out appointments. They should stop fooling themselves and book a longer day at the office. They are staying late anyways; they might as well do the courtesy of allowing their patients to arrive later instead of making them sit in the waiting room for hours.

Either way, it’s up to physicians to keep their own waiting rooms empty.

3. Waiting for blood-tests and X-Rays – Lab tests can be processed in minutes to hours, but we make patients book separate visits to get blood-work and imagining, then we make them book another visit to discuss the results! Basic blood-work and x-rays should be available same day for all patients. This can be done by allowing advanced access at labs and imaging suites. Digital images can be read off-site.

Patients could receive basic tests and results in the community just as they do in the ED without extra cost to labs and with great savings for patients.

4. Waiting to see specialists. Ostensibly, wait times to see specialists are long because there aren’t enough specialists. However, there’s a glut of unemployed specialists in many fields (e.g., orthopedic surgery, cardiac surgery, etc). Most of the specialists are ‘unemployed’ because they can’t get operating room time. If there really are too few specialists, why don’t they leverage family docs (or unemployed surgeons) in their clinics to screen through their consults and follow-ups?

I worked for a few years as an associate with our local vascular surgeon to churn through his office visits and minor procedures so he could focus on patients needing surgery.

5. Waiting in an ED waiting room – We discuss how to close your waiting room in other posts. It’s the right thing to do – get patients inside, get them seen, get them treated.

6. Waiting for an inpatient bed inside the hospital – There is no reason to warehouse patients in emergency departments. Unless hospitals make a conscious decision to get patients up to the wards, nurses and physicians will not change their behaviour and get patients upstairs. Dozens of papers show that quality and patient satisfaction improve when patients wait in the halls on inpatient wards instead of waiting in the ED. Furthermore, hospitals that send admitted patients up to the wards, when there are ‘no beds available’ on the ward, somehow find a way to put patients into rooms. Staff find a way to discharge other patients to open up space.

Admitted patients should never be left in the ED to wait for an inpatient bed.

7. Waiting for surgery – Patients wait because OR time is limited by OR closures or cancellation of surgery. ORs need to be kept open – after hours if necessary – to treat patients. Surgery must not be canceled because surgical beds are full of medical patients.

Let surgeons manage surgical beds; do not let medical flow issues shut down surgical flow.

Rebuttals

1. If we remove waits, won’t demand go up? Won’t utilization increase? Anxious patients who demand ‘unnecessary’ investigations receive those investigations in the current system. Most average patients don’t want to give blood or get X-Rays and then wait around for results unless they really have to. Average patients would continue to pursue investigations only on advice from their physicians.

2. Wouldn’t MDs start ordering too many tests if they knew they could get same-day results? Sure, more family docs might order blood-work and X-Rays for patients that they presently send to the ED preventing a few ED visits. Same day service would still require hours of waiting for patients; hardly a convenience all patients would want. The current technology for blood-work and x-rays still dissuades frivolous testing because of the time and effort required. Until investigations become as quick and convenient as a medical scan on Star Trek, we won’t see a giant spike in investigations.

Canadians wait politely, and they should not. There’s no need for most of it.

We need to challenge the old way of doing things: waiting for appointments, waiting in waiting rooms, waiting for labs, waiting for x-rays, waiting to discuss results, etc, etc…

We need to adopt a ‘get it done now’ approach all across healthcare.

If you agree, feel free to leave a comment by clicking on leave a reply or # of replies.

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?