Now that the Joint Commission on Accreditation of Healthcare Organizations has acknowledged that overcrowding is a hospital-wide problem requiring broad problem-solving strategies, remedies to ED overcrowding may be at hand. (Davidson SJ. EMN 2004;26:24.) But for a variety of social and demographic reasons, overcapacity problems are likely here to stay. Despite directives from the JCAHO to address these problems at the institutional and community levels, no department can afford to wait for outside organizations to solve this problem entirely.
Each must try to finesse the situation at his facility using available resources, through continuous process and policy improvements and small unsung innovations. (Spaite DW. Ann Emerg Med 2002;39:168.) While small process improvements and equipment innovations may not offer a grand solution to problems of overcrowding, they can make the ED journey better for small subsets of patients and more efficient overall.
Practitioners on the front lines have to begin to view each patient care area in terms of bed minutes. Each patient care area represents slightly less than 1500 bed minutes available for patient care a day (24 hours x 60 minutes). Any process, operation, or system that slows patients' passage through that bed effectively consumes bed minutes, which are a finite resource. Admittedly some bed minutes have more value than others. Bed minutes spent giving critical care to a septic patient have more clinical, financial, and service quality than bed minutes spent with a patient waiting due to operational delays. (These have no value.)
Staff energy is another finite resource. Patients with long turnaround times demand a disproportionate amount of our human resources. If you doubt this, think about the last disgruntled patient you cared for. It is likely he required food, a bed pan, and a phone as his visit was prolonged. (Augustine J. ED Strategic Planning and Process Redesign. Presented at Benchmarks 2004.) Inevitably you and your staff then expended great energy to smooth over the unhappy patient/customer. To maximize departmental efficiency, emergency physicians, nurses, and administrators can't tolerate even small glitches or delays in ED operations because they consume bed minutes and staff energy, which are not limitless.
Musical Beds, Medical Error
Papers and books have been written about the futuristic ED. Most schemes include greater point-of-care testing with more treatments and tests performed at the bedside. Increasingly, the old model of trundling an ED patient off to the bowels of the hospital for diagnostic interventions is being turned on its head. The most efficient ED would be the one in which every diagnostic and therapeutic intervention would be available from every patient care bed. Moving patients around the hospital (say to angiography) may be necessary, but moving them around the emergency department is inefficient, dangerous (“What happened to the lady in bed 9?”), and increasingly unnecessary. Musical beds in the ED is a guaranteed recipe for medical error.
With that ideology in mind, consider three homegrown inventions that facilitate making every patient care bed multifunctional. The RSI Cart (photograph 1) was an outgrowth of a quality improvement project which revealed that less than one percent of the time did we require a fully stocked difficult airway cart” for our ED intubations and that most physicians in our group used the same drugs for intubations. Data also revealed that we perform nearly one crash intubation a day.
Armed with these data, we first developed an RSI Drug Pouch (photograph 2). Because we use succinylcholine vials at such a rapid rate, we saw no logic in refrigeration to prolong shelf life. This allowed us to put all the drugs we use and their proper diluents and syringes in one handy pouch. As perks, we threw in charge sheets to keep the pharmacy happy and laminated dosing cards for the skittish or inexperienced nurse. These pouches have become hugely popular in our department, and when a physician calls out, “I need a red pouch in room 2,” it is now in the popular lexicon that this means an imminent intubation. Magically, the appropriate personnel, (the respiratory therapist and the x-ray technician) appear at the bedside for an emergent intubation.
Building on this idea, we created plexiglass carts with plastic locks indicating that they are fully stocked with blades, tubes, stylets, and other basic airway supplies along with the red drug pouch. They roll easily from bed to bed, allowing any stretcher to be used for acute airway management. They also have flat surfaces for laying out airway supplies prior to intubation. With the RSI Cart and a portable monitor, any patient bed becomes a critical care bed.
The second innovation was in response to poor turnaround times on simple lacerations, and was also part of a quality improvement initiative. We felt that at least some of our delays in laceration repair could be attributed to the lack of suture beds. We essentially have one location for suturing, and patients are in queue for long periods, especially in the summer. So we recently designed the Portable Suture Station (photograph 3). This is another cart that has been fully stocked with laceration repair supplies, has a portable light source, and a retractable extension cord. With this station, any patient bed can be a suture bed, even in the hallway.
Dashboards and Movable Triage
Quality improvement data led to yet another innovation within our department. With newly operational Dashboards visible on our integrated tracking system, we can see flow problems as they occur in real time. Dashboards are in themselves another innovation we developed with our information technology staff. These are real-time data captures to identify operational bottlenecks as they occur. We can see a backlog of patients presenting to triage as patients begin to line up.
We then devised a movable triage station (photograph 4). We have a computer on wheels for nurse triage charting and a vital signs station on wheels. With two chairs, the nurses can set up an ancillary triage station anywhere in the ED to facilitate entry of patients into our system. Though we have bedside registration, we still prefer a brief triage to help route patients to the proper location in the department.
Emergency departments across the country have the potential for developing small equipment innovations or process improvements that can be shared and adapted to different settings. While these small focused improvements may not be a grand solution to flow problems, they may make operations better for some. Each fine-tuning endeavor serves to improve a microcosm of the whole. Each department and its staff should be thinking of the work environment as a laboratory for such innovation. And no multicenter longitudinal study is required to demonstrate efficacy. Sometimes a good idea is obvious.
As practitioners trying to navigate these choppy patient-flow waters, we can benefit by embracing the idea of multifunctionality in our departments. As ED overcrowding exerts pressure on our operations, we always have to think in terms of bed minutes and identify processes that add and subtract from our finite resources. Taking data from our practices, deciphering the messages implicit in the data, and manufacturing real, tangible, practical solutions is what quality improvement is all about. Small innovation by small innovation, we make what we do and how we do it better for our patients. Though many of the mainstream emergency medicine journals seem almost hostile to quality improvement research, these small proprietary data sets and their resultant innovations are well worth sharing.
1) Davidson S J: Managing Patient Flow: A Challenge Mandated by the JCAHO. EMN Dec. 2004, vol. XXVI, (12).
2) SpaiteDW: Rapid Process Redesign in a University-based Emergency Department: Decreasing Waiting Time Intervals and Improving Patient Satisfaction. Ann Em Med. 2002; 39:168–177.
3) Augustine J: Numbers Shouldn't Make You Numb: Statistics and the Operation of your Emergency Department. EDBA Survey Fall 2004, Unpublished.
4) Augustine J: ED Strategic Planning and Process Redesign. Presented at Benchmarks 2004, Orlando.
5) Smith MS: The Next Generation ED. Ann Em Med 32 (1) 65–74. July 1998.
6) Huddy A: Emergency Department Design: A Practical Guide to Planning the Future, ACEP press, 2002.