Saturday, July 14, 2001

Patients are waiting. There are delays in my ED. And I’m doing something about it. - Part 2 (of 2)

Last month I wrote about some of the ways you might measure how long patients were waiting in your ED. This month I’d like to suggest some approaches to reducing the waits and delays your patients experience and your community fears.

While many different approaches to evaluating and reducing waits and delays have been used, probably one of the best breaks the patient care episode into three periods. Everyone at Maimonides Medical Center knows that we track "T1, T2 and T3." These three intervals mark the period from patient arrival until first physician contact, initial physician contact until a disposition decision is made and lastly the period from disposition decision until the patient physically leaves the ED. Various consultants use a variety of terms, the Advisory Board Company for example names the same three intervals in terms of their recommendations for improvement: "Expediting Time to Physician," "Expediting Diagnosis" and "Expediting Inpatient Admission." Of course this leaves those patients who are discharged—usually the majority of those patients seen. Perhaps this is not an issue in your ED, but in ours, where our physicians teach the patients, handing the printed discharge instructions to the patient, this is an issue.

Your efforts at reducing waits and delays should be focused where you’ll gain the greatest benefit, but it’s important to be practical and for most of us it’s more realistic to start with processes that take place entirely within the ED rather than processes that involve outside departments. Clearly, if everything in your ED is running perfectly, except for the interval to get a chest x-ray or CBC, well then you have to go where to the problem. But for most of us, working to reduce "T1"-the period from patient arrival until first physician contact is a good place to start, because while it involves workers who may have different managers or supervisors, the workers are all based in the ED and are accustomed to working together. Both of the other intervals require working with personnel based in the lab or radiology departments (if addressing "T2") or on the floors (if addressing "T3"). Starting in the ED says to others that you are serious about first cleaning up your own mess.

Among the most commonly adopted approaches to reducing "T1" is bedside registration while the patient would otherwise be waiting. Not sending the patient back to the waiting room after triage also gives the patient the sense that they are moving forward in the process of care. Instead, with the patient on a stretcher, register the patient. If your ED is low-tech, a clerk can do this with a form, interviewing the patient and entering the information into the computer at a later time. If your ED is high-tech, the clerk can use a wireless-networked workstation wheeled up to the patient’s bedside. If space and funds are available, a PC can be placed at each patient care location, but based on experience I think this is the least useful approach as crowding often makes it difficult to reach these. But perhaps that’s just Brooklyn and your ED isn’t that crowded (tongue firmly in cheek). Electronic medical records impose their own banal logic on registration, as many systems won’t allow entry of orders or observations prior to patient registration. The electronic handcuffs thereby applied may force registration earlier in the process of care. An abbreviated triage with a short registration entered by the triage nurse solves the problem.

The key factor here is using the waiting time productively. Many opportunities for using waiting time exist early during the patient’s ED visit. A brief triage followed by a more complete assessment by the first available practitioner, whether physician or nurse can facilitate the ordering of laboratory tests or imaging studies through either physician order or nursing initiation of standing medical orders by protocol. In either case, the results will be available sooner than waiting for complete physician assessment. The downside of over-utilization is a risk of this early testing strategy, but monitoring with feedback to the entire group can mitigate the problem through the "Hawthorne Effect" and the tendency for any group of people to modify their behavior to be in-line with that of their colleagues.

Brief triage reduces waits by freeing the triage nurse for the next patient, thereby reducing the waiting time for triage itself. You may not be aware of this wait, I’ve not described it above and we’ve only started to track it, but this "T0" the period from patient presentation until triage can be a cause for significant patient displeasure and morbidity. Both reticent patients, and those seriously ill, may not make enough of a fuss to receive an urgent response and while waiting quietly, deteriorate.

Another intervention, though not reducing the "T1" interval will reduce the "T2" interval. Many times patients wait for the physician to make a decision even though laboratory results have become available, but the physician is not aware of them. Bringing the lab results directly to the physician along with the chart can reduce "T2" as absent an electronic tracking system, the physician must periodically check to see if results are back from the laboratory thus interrupting other patient care work. By knowing that the results and the chart will come to her when results become available, the emergency physician will interrupt other work less often and through the prompting provided by the chart and results together will disposition the patient that much sooner.

Reducing waits and delays not only improves your patients’ experiences in your ED, your Emergency Department’s standing in your community and your administration’s perception of you, but it also provides you with the capacity to see more patients. Since as patient move through more quickly you open up space to see the next patient, surely an effective response to the continuing growth of volume in most of our EDs.

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