Back in 1996, the groundbreaking emergency department drama “ER” aired an episode that probably still holds a place in the heart of many emergency physicians. “A Shift in the Night” found attending physician Mark Greene (Anthony Edwards) along with a team of nurses and young resident John Carter (Noah Wyle) trying to manage the chaos of a crowded and understaffed ED on their own.
Things reach a breaking point around midnight when Greene finally sees a young boy who had cut his hand and has been waiting for hours, despite his mother's pleas for attention. They have been waiting so long, however, that the risk of infection is too high, so Greene can't stitch up the wound. Instead, the boy will have to wait two days for an additional procedure.
Greene decides to take drastic action: he eliminates the waiting room. To be exact, he takes the staff into the waiting room and turns it into a patient care space, treating the patients there where possible, with no long admission questionnaires and no elaborate triage. The result: a rapidly cleared board. Heading home, Carter tells Greene that this is what he thought medicine would be like when he first started medical school. “That's what it's supposed to be about,” replies Greene.
Maybe Mark Greene (or Neal Baer, the pediatrician who wrote “ER”) was about 15 years ahead of his time. Today, emergency departments in many major hospitals are taking creative new approaches to minimize wait times and triage. Some of them, like Brigham and Women's Hospital in Boston, have taken the previously unthinkable step of eliminating the emergency department waiting room all together.
Joshua Kosowsky, MD, the clinical director of the Brigham and Women's ED and an assistant professor of emergency medicine at Harvard Medical School, and colleagues Eric Goralnick, MD, and Ron M. Walls, MD, described how their department undertook a dramatic, Lean-style reengineering of the entire emergency culture at their hospital in the Harvard Business Review blog. (http://bit.ly/1ceFlAu.)
It all began in 2009. “We provided care for 57,532 patients that year, and our quality and safety metrics were excellent,” wrote the physicians. “Our patients, though, on average, had to endure a wait of more than one hour to see a physician. More than 3 percent of our patients simply walked out, reasonable by academic medical center standards, but by no account desirable.” Patient satisfaction scores ranged between the sixth and 40th percentiles when compared with similarly-sized academic emergency departments.
The financial crash had derailed a planned doubling of the ED's square footage, and Dr. Kosowsky and his colleagues knew that they couldn't just get bigger; they had to get better if they wanted to improve matters. An 18-month Lean process identified some key bottlenecks to patient flow, one of the biggest of which was nursing triage. They took, in response, what might seem like a heretical step: they eliminated triage.
“That's the elephant in the room of front-end bottlenecks,” Dr. Kosowsky said. “Why do we go through this process? It sounds like a silly question at first. How could you not? That's how you find out how sick the patient is. But when you take a step back and think about it, you realize that triage plays a role when you have very limited resources and have to pick and choose who you can take care of. You don't get triaged at the car wash. When you're standing on line at the supermarket, they don't triage you. If the line gets too long, they open another register. That's how it should be in EDs: triage should only take place to identify the truly life-threatening emergency where every second counts. Surges may occasionally need triage, but that should be rare.”
The elaborate triage process made sense in decades past, before emergency medicine was a full-fledged specialty and not all EDs might have had a competent emergency physician on hand at all times or the facilities to take care of all patients. “The triage nurse was deciding, ‘I'm going to call cardiology for this patient, send this patient to the GYN suite, and this patient to orthopedics,’” Dr. Kosowsky said.
But today, he argued, segregating ED patients into smaller and smaller buckets doesn't make sense. “There is a lot of industrial engineering theory and practical experience showing that every time you separate patients into different groups, you build in inefficiency.” Anyone who has an ED that runs different tracks — acute, semi-urgent, and fast-track, for example — will appreciate this point. “Some days you'll have a full waiting room, but when you walk in the back, you'll see there's space, just not the right kind,” Dr. Kosowsky said.
The Brigham and Women's ED adopted the principle that the physical plant and staffing must be set up in a way that virtually any patient can be cared for in any bed. That doesn't apply in every single situation, of course; an acutely psychotic patient may need his own segregated space, for example, and a major trauma requires an entire trauma team. “But you don't build your front end based on the 10 percent of the time you're surging. You build it around the other 90 percent,” Dr. Kosowsky noted.
Patients arriving at the Brigham and Women's ED don't go to the waiting room because there is no waiting room. The former large waiting area and triage space has been transformed into a medical-clinical area. There's a small booth where patients quickly get registered by a rapid assessment nurse and then brought back to a bed in a process that usually takes less than 10 minutes. Family members can wait in a small part of the main hospital lobby that the ED “cannibalized” as a waiting area, but it's almost always empty, Dr. Kosowsky said, adding that sitting in the waiting area is not part of the routine.
The department's two mantras are “Any patient, any bed,” and “Stay a bed ahead.” Those ambitious goals are achieved by a rotating team of eight experienced emergency nurses (six full-time and two per diem) who do no patient care. They are flow managers, a position that is staffed 16 hours a day, who do for the ED's patient flow what air traffic controllers do for jumbo jets. “Their entire focus is making sure we have a bed for the next arriving patient,” Dr. Kosowsky said. “They work with our clinical staff to identify local bottlenecks and move patients out of our pods as soon as they are stable, either to discharge, admitting, or to the internal waiting area or observation.”
One of the first flow managers was Ann Carey, RN, who came to Brigham and Women's three years ago from a community hospital in Framingham, where she had worked as a “throughput nurse,” a position she thought would be similar to her new job.
“But that was a clinical position,” she said. “Here, we strictly are on the floor helping to manage the department. We're calling the floor to see if they can take patients, rounding with the attendings to see what the patients need and what we can do to help facilitate that.”
Ms. Carey and her colleagues have a global view of the four ED pods that the charge nurses overseeing individual pods do not. “I generally assign patients in a strict rotation, around in a circle, from one pod to the next,” she said. “But as the pods start to get busier and we have acuity, I'm aware of that. And we take all the ‘expect’ calls, which we get quite a few of as a Level I trauma center, so I always know what's coming in.”
Four years after they decided that something had to change, the Brigham and Women's emergency department has cut its average door-to-bed time from 65 minutes in 2009 to 22 minutes in 2013. More than half of all patients are in a bed within nine minutes of arrival, and walkouts have been cut by more than half, from 3.3 percent per month to less than 1.5 percent. All of that has happened as volume has increased to more than 60,000 visits annually.
Not surprisingly, patient satisfaction scores have risen commensurately, from the lowest quartile to as high as the 99th percentile. They have remained at or above the 90th percentile for seven of the past nine quarters, Dr. Kosowsky reported.
Some other EDs have taken similar approaches — large-volume EDs such as Kaiser Permanente's South Sacramento Medical Center in California and lower-volume ones like Adventist GlenOaks Hospital in Glendale Heights, IL — and reported similar improvements in wait times, rates of patients leaving without being seen, and patient satisfaction.
Could this model be replicated anywhere? “You can only do so much with process,” Dr. Kosowsky cautioned. “If you have a LWBS rate of 25 percent because you don't have enough staff to see all the patients who come to your door, that's another issue. Different EDs have different constraints, whether it is the physical size of the space, their staffing model, or external constraints like lab turnaround time or boarding time for inpatients.”
But for many EDs, eliminating unnecessary, self-imposed inefficiencies such as reliance on bulky triage processes and waiting rooms can potentially compensate for a fair amount of systems problems. Mark Greene would be proud.
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