What can you expect if you are lucky enough to work in an emergency department that expands and renovates, nearly doubling the number of beds and installing state-of-the-art technology? Bigger crowds of patients, that's what.
Just ask emergency physicians at the stunning new ED at Vanderbilt Medical Center in Nashville. There, ambulance diversion occurred on the very first day the bigger, refurbished ED opened its doors. “We have run up against a buzz saw of growing volume,” explained Ian Jones, MD, the director of the Adult ED at Vanderbilt.
Or, as Corey Slovis, MD, put it: “If you build it, they will come.” Dr. Slovis, a professor and the chairman of emergency medicine at Vanderbilt, said there is a lesson to be learned in his ED: Expansion alone, such as adding 25 beds to the previous 28, will not solve most ED problems.
As anecdotal accounts throughout the medical literature illustrate, the ED at Vanderbilt is not the only one to experience recurring bottlenecks immediately after undergoing construction aimed at alleviating them. The investigation in Nashville, however, may be the first to document the finding in such a scientifically valid way.
In researching the effects of the expansion, the Vanderbilt team yielded fairly depressing but apparently irrefutable data. Mean length of stay in the ED went up by an hour post-expansion (from 4.6 to 5.6 hours), and there was no reduction in ambulance diversion during the five-month study period. The proportion of patients who left without being seen went down, however, from 3.5 percent to 2.7 percent, and concurrently, patient satisfaction scores improved.
But why, even after the expansion, did crowding persist? “We couldn't really track why this was occurring,” said Jin H. Han, MD, the lead author of the study relaying the ED's experiences. (Acad Emerg Med 2007;14:338.) The answer seems evident, he speculated, in the phenomenon that exists nationwide: Admitted patients were boarding in ED beds a lot longer because beds in the hospital were simply unavailable.
Although the ED expansion eased the way to more patient processing, a parallel surge was happening other places in the hospital, he explained, namely the number of elective surgeries and cardiac catheterizations increased. Patients receiving these elective procedures were filling hospital beds to capacity, said Dr. Han, an assistant professor of emergency medicine. “It's a good problem to have,” he added, noting that a new wing is under construction to meet this inpatient increase.
In addition, the state has been discharging large numbers of patients formerly on TennCare, the state-funded health program for the indigent, Dr. Jones said. As a result, the uninsured constitute a larger percentage of the ED patient load than ever before. These are the same issues being faced by other EDs across the country, where influx is coming from across the economic spectrum, he said.
And, as Nashville continues to grow, so will the demand on the ED, he predicted. The city has become a magnet for industries outside its traditional core of music-related business; Nissan headquarters, for example, is a new corporate resident.
Today, the combined volume of the Vanderbilt adult and pediatric EDs is approaching 100,000 patients per year. In contrast, patient census was only about a third of that a decade ago, Dr. Jones said.
Team Spirit Flourishing
With such growth, it's a real feat not to have patients on gurneys in hallways, which his ED is able to avoid a lot of the time, Dr. Jones said. On the other hand, team spirit is flourishing. “We are like an assembly line here, figuring out how to do it better as we go,” Dr. Jones said. “We do occasionally have trouble keeping up but we are staying ahead.”
Staff morale is high, Dr. Han concurred. The reason is no mystery. “Leadership has been very responsive,” he said. “We are all working as a team in a problem-solving way, not just those of us in the ED but from the hospital, too. That is a very positive thing.”
One other plus of crowding is that it necessitated a new staffing model for high-volume ED shifts: An extra emergency physician. Now, during peak times, one is in the waiting area helping manage patient flow, assisting with triage, and explaining the reason behind delays when they occur. Patient satisfaction scores are high, proving that having an emergency physician out front and adequate communication in the waiting room help make long waiting times bearable, Dr. Han pointed out.
One lesson from the Vanderbilt experience is that total throughput time is not necessarily reflective of efficiency, Dr. Jones observed. In fact, his ED is more streamlined than ever. There are shorter in-room times for patients, thanks to a senior physician and care team stationed in the waiting room who order tests before the patient reaches an exam room, he said. Additionally, there is more effective utilization of nurses by adding paramedics and techs to the patient care team and by having many labor intensive tasks completed by the time the patient reaches a bed, he added.
Dr. Slovis also points to greater efficiency as key in helping mitigate patient flow. “The key to managing throughput is to use beds for those who need them, do more tests while patients stay in chairs or lounges, and to begin work-ups as soon as possible, often before the patient is in a room,” he said.
The real issue for many academic medical centers is not just the length of time to do work-ups, but that hospitals will use excess capacity to observe or board patients in the ED. Space alone is not the answer, Dr. Slovis said. “Until we solve the primary care problem in this country with a major investment in outpatient medical care for routine health care, we will never fix the ED patient volume.”