Patient Safety Requires Abundance

How much more can you work?

10%?…25%?…50%?

Do you work too much already?

Emergencies demand MORE.

You risk patients’ health if you cannnot respond to increased demand.

Abundance

Most departments run on a poverty mentality: serve as many patients as possible doing as little as possible for each. Parsimony appears wise, even frugal, but it’s backward and unsafe.

A poverty mentality fosters a dysfunctional system with no resilience – nothing extra, no reserve for disaster, no teaching, no service excellence, no follow-up, only the bare minimum.

Abundance turns poverty on its head. Why not do as much as you can for every patient? Instead of sprinting through diagnosis and discharge, why not provide over-the-top care and service? Why not welcome patients back if they can’t get great follow-up that works for them?

Abundance means treating all patients like they were privileged. Privileged patients get all the extras without extending their stay.

Abundance provides outstanding patient experience AND builds resilience – the ability to flex; to increase services on demand – necessary to guarantee safe, quality care for the next wave of patients. Poverty delivers second-rate care and jeopardizes emergency services for the whole community.

Objections:

1. “But great service will just increase volumes!”

2. “Can’t most of the patients be seen in a clinic?”

3. “Won’t abundance increase costs?”

Objection #1 This has to be the dumbest reason to not improve service. If volumes increase because your service is great, so be it. Hopefully, other EDs will improve, too.

Objection #2 True, emergency departments exist to care for the acutely sick and severely injured. Emergency services require

I. Capacity to care for the acutely sick and severely injured,

AND

II. A dependable method to sort out patients who aren’t sick or injured.

I. Patient resuscitation for the acutely sick requires 3-4 nurses, at least one MD and a horde of other staff to attend immediately. Ask ED staff:

Have you had 2 resuscitations at the same time?

How about 3?

Have you ever had 4 resus patients at the same time?

These scenarios are NOT rare. While the answers depend on your annual visits, guaranteeing immediate care might demand up to 16 nurses, a team of allied health providers and a group of MDs.

II. No method can guarantee that patients sent away from an ED won’t come to harm. All EM staff have seen patients triaged to a minor treatment area only to be admitted to the ICU or sent for emergency surgery. Sore throats and back pain can turn out to be life-threatening epiglottitis or aortic dissection. Why not see them in the ED?

Objection #3 “ED care costs too much.”

So, why don’t we send patients straight to a clinic where they’d be seen immediately? A clinic could assess patients, perform routine investigations, get urgent access to x-rays and even provide IV treatment.”

Indeed. And how would the costs differ?

Fixed costs for EDs are huge, but it costs very little to see one more low acuity patient – far less than a separate clinic. And, low acuity patients NEVER block up the ED.

In Canada, EDs back up everything else – doctors’ offices, post-op clinics, imagining, consultant services, etc. An abundance mentality guarantees that no matter what happens, patients will receive immediate, high-quality care. EDs must create their own resilience with an abundance approach to service or risk emergency preparedness for their whole community.

How much more can you do – today – for patients in your ED? Are you risking your community by fostering a poverty mentality?

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?

Waiting harms patients – A novel idea?

A room full of unbelieving faces stared back at me. I had just finished presenting a brief review of the negative clinical impacts of patient waiting.

They didn’t buy it. My medical colleagues flatly rejected overwhelming evidence.

Why?

It’s been said that every idea must pass through 4 stages:

1. Critics scoff at your new idea because it’s novel and lacks supporting data.

2. After gathering data, critics say it lacks significance or is biased.

3. Eventually, your idea catches public interest. It gains popular support.

4. Finally, everyone accepts your idea, and the critics tell how your idea was theirs from the start.

Despite hundreds of papers clearly demonstrating harm for patients due to waiting, we will never see improvement without popular support.

We need to engage the public – educate them – on the risks to their health when they wait in crowded emergency departments. We need hospital leaders and governments to understand that waiting harms patients.

We need to challenge our cherished clinical processes that have been designed to benefit providers, but actually add harmful waiting to patients’ experiences.

We need to share solutions – brave innovations – that strip all the useless, harmful waiting out of our patients’ time in our institutions.

At which stage are you in realizing that waiting harms patients? What needs to be done to recruit you, and others, as champions to help STOP Patient Waiting?