Welch, Shari J. MD
The room fell silent. A layperson sitting on the Technical Expert Panel convened by the Centers for Medicare and Medicaid Services in 2007 quieted everyone with a mere 16 words: “I don't see what x-rays and lab tests have to do with ED efficiency and performance.”
Consider it a victory that emergency physicians have made a case to CMS that ancillary service support for the emergency department is critical to efficient operations and performance. A roster of performance measures being considered by CMS includes turnaround time for labs and imaging studies. With pay-for-performance in the wings, this will likely help emergency departments get the services they require to move patients efficiently.
That said, we have a lot of work to do as a specialty to determine best practices for the ancillary services that support the ED. Improving laboratory turnaround times can improve overall length of stay. (Acad Emerg Med 2008;15:1130.) Emergency departments typically manage lab specimens in one of three ways, and some use a combination of all three: an ED stat lab, point-of-care testing, and an ED-based lab technician. ED-based stat labs and point-of-care testing have been shown to improve ED efficiency (Acad Emerg Med 2008;15:324; Clin Chim Acta 2001;311:67), but the verdict is still out on which strategy is the most efficient.
Today's hospital laboratories are fully automated, and the turnaround time from arrival of the specimen in the lab until the results are received in the ED is typically under 30 minutes. Attention to the collection of specimens and their delivery to the lab, however, is becoming an appropriate focus. There are no published data yet on the efficacy of placing a dedicated lab technician in the ED to manage specimens, but the Advisory Board began recommending a dedicated ED lab technician to eliminate delays and improve efficiency in its sentinel publication Building the Clockwork ED. (Washington, D.C.: HWorks. An Advisory Board Company; 2000.) Though also never published, VHA through its survey database identified the ED-based lab technician as a best practice in 2005, a finding presented at numerous conferences about ED operations.
Whichever method of lab specimen management is adopted, there is no question that a hospital pneumatic tube system for transporting specimens to the lab (and medications from the pharmacy and paperwork between units) is considered a best practice. (J Emerg Nurs 2006;32:139.)
Delays with imaging studies are a source of patient-flow bottlenecks in many emergency departments. Data from the Emergency Department Benchmarking Alliance (EDBA) survey show that utilization of imaging continues to climb, and higher-volume, higher-acuity emergency departments have higher rates of imaging. (Ann Emerg Med 2011;58:33.) The average emergency department doubled its census in the past 20 years, but most departments are still being built with only one x-ray suite and one CT scanner. The Chandler Hospital at the University of Kentucky, which sees more than 50,000 patients a year, found CT scanning was a clear bottleneck to flow, and added a second scanner to their new ED. (J Emerg Nurs 2010;36:303.)
The Advisory Board recommended a dedicated x-ray technician for the emergency department as a best practice. The EDBA in more unpublished work identified the use of transport technicians to and from radiology as a strategy to improve imaging efficiency for the ED. (Why have an x-ray technician pushing stretchers when he can be taking films?)
Hand in glove with these ancillary services are the IT systems that allow them to transmit data to the emergency department. The advantages of an electronic whiteboard or tracking system in the emergency department have been well recognized. (Int J Med Inform 2005;74:827.) The best systems send an electronic cue to the emergency department when a patient's lab or x-ray results are available, and providers can access them through the electronic white board.
The benefits of information technology integrated into workflow have been reported in the literature, but it is still an area in its infancy. (Acad Emerg Med 2010;17:527; Acad Emerg Med 2010;17:1312.) Emergency departments must take into account the space that this new technology support requires. The departments most advanced in having information technology integrated into workflow are operating with a computer for each member of the health care team, including social workers and case managers. This will mean that computer stations to accommodate all of the staff will need to be factored into the ED design and space.
As electronic medical records (EMR) are adopted more and more, the modern ED will require banks of common-use computers that any staff member can utilize. Respiratory therapists, ECG and x-ray technicians, and a whole host of other providers are in the department transiently while involved in patient care. They need to communicate electronically regarding the patient's progress and to place information on the electronic whiteboard or tracking system. Even housekeepers may need to cue when a patient room is clean. To get an idea how many computers may be required as hospitals become fully invested in a comprehensive electronic medical record, the Pebble Project in the University of Kentucky Chandler emergency department used predictive modeling and forecasting to design a 50-bed emergency department. They estimated the department should be provided with 240 computers for staff!
The point is this: It is time to evaluate your emergency department's ancillary services and IT support. Emergency medicine is a team sport, and ancillary services should be expected to step up to the plate with efficient service. Benchmarking data from VHA and Premier have shown that top-performing EDs are pushing the envelope, and the median time for lab and imaging turnaround has been declining. It now approaches 45 minutes from order to results. Are your ancillary services serving you that well? And by the way, what is your computer count?
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Dr. Welch is a fellow with Intermountain Institute for Health Care Delivery Research, an emergency physician with Utah Emergency Physicians, and a member of the board of the Emergency Department Benchmarking Alliance. She has written two books on ED operational improvement; the latest, Quality Matters: Solutions for the Efficient ED, is available from Joint Commission Resources Publishing.
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