If you wanted to study the British health system after the government imposed limits on how long patients should stay in emergency departments, there probably would be no better way to start than the one undertaken by Ellen Weber, MD. She accompanied her injured niece to an English ED.
Dr. Weber, a professor of clinical emergency medicine at the University of California, San Francisco, said it was a striking irony that she had taken a sabbatical nearly five years ago to conduct research on the National Health Service's length-of-stay mandates for EDs. She anticipated poring over reports and observing clinical services, but never expected to become a “secret shopper,” she said.
But that is just what she effectively became when her niece hurt her ankle while dancing. Dr. Weber used the Ottawa ankle rules, but still couldn't determine if the injury to the young woman was a fracture or a sprain. So, off to the ED they went, where a senior physician encountered the same problem. Coming to the same conclusion as Dr. Weber, the emergency physician ordered an x-ray and then ruled out a break.
“My niece never had a vital sign taken nor was she ever assigned her own room,” Dr. Weber recalled. “And that was completely appropriate.”
The biggest difference she observed during her study of the NHS length-of-stay rule that year was that they recognized the constraint on resources in the way they practice, Dr. Weber said. A full set of vital signs was not taken on every patient; head traumas were handled by observation instead.
“They tend to rely more on clinical judgment and the patient's history than imaging and labs,” Dr. Weber said. “They don't go looking for the one case out of a thousand where someone had an ankle sprain and forgets to tell you they fainted first.”
The situation is in stark contrast to the way emergency care is practiced in the United States for the most part, she noted. “In this country, we seem to have this philosophy that we can do everything all the time for the patient,” she said. “But we really don't have those resources either. We're ignoring the resource of our clinical judgment and our clinical experience to practice more efficiently.”
Could this approach work in a typical American ED, with its pervasive risk of litigation and its urgent surge of patients? Some emergency physicians in academic settings similar to Dr. Weber's have also wondered how the British approach might translate to emergency care across the pond. Peter Viccellio, MD, a clinical professor and the vice chair of the emergency department at Stony Brook (NY) University Hospital, said he believes such time-targeting “is entirely dependent on the system upon which it is imposed.”
The idea of a government mandate is intriguing, said Richard Zane, MD, the chair and a professor of emergency medicine at the University of Colorado in Denver. Each ED has islands of time that can be used more productively, he explained. “Should triage even exist?” he asked. Or, if it is deemed necessary, can it be streamlined?
A minute-by-minute analysis is being done in his institution to identify periods when productivity can be increased. Two different pieces of information can be assessed by following the time stamps of procedures for individual patients: where patient time is most labor-intensive for nurses and physicians and when repetition occurs by staff. Repetition doesn't simply mean doing the same test again; it can mean ordering one because of the results of another. “It may be more costly to have both tests done at the same time, but do we know that? Because it may save time to do that instead of saying, ‘If test X doesn't show this, I'll order this other one,” he said.
Dr. Weber and British and Australian researchers have since published accounts of the four-hour time-target in England and how it was achieved. One factor was consistent with success in more than a dozen hospitals involved in her study of the system: hospital-wide collaboration. She and her co-authors found that system-wide cooperation was required for compliance with the mandate, even when they found widespread ED re-engineering. (Ann Emerg Med 2011:57:79.)
The Australasian College of Emergency Medicine, which is looking at time-based targets for Australia and New Zealand EDs, found good news and bad when examining the United Kingdom's NHS time-targets. The four-hour mandate helped some hospitals practice more effectively, but others sank into dysfunction trying to meet the targets. That dysfunction included gaming the data, diverting funding incentives away from the ED, and bullying by nonclinical managers. (Emerg Med Australas 2010;22:379.)
Or, as an article on physician productivity in the United States asked during the same period when the British mandates were in effect: When physicians are providing the same services as before, but fewer services are being allowed, is that really a reduction in output? (Health Care Financ Rev 2007–08;29:41.) More recently, researchers assessing how admissions of high-risk patients were cut among Medicare beneficiaries found that the answer seemed to have more to do with patient communication than clinical service. Follow-up phone calls and provisions for patient education were linked to admission reductions. (Health Aff [Millwood] 2012;31:1156.)
Such measures may help, but there is ample reason to view the emergency care as time-saving at most hospitals. “Generally, the ED is able to accomplish diagnostic workup, even if it is extensive, much more quickly than inpatient services do,” said Dr. Viccellio. Traditionally, diagnostic tests and consultations that are ordered one day for hospitalized patients may be performed the next or even several days later, he said.
“This has got to get fixed, too,” he stressed. “Such practices unnecessarily prolong the total length of stay in the hospital, tying up crucial resources.”
Setting a mandatory time limit for the ED in door-to-discharge or admission oversimplifies the problem and the solution, Dr. Viccellio said. “The overall benefit to either the patient or the system is unclear,” he said. “We really need to carefully examine the inpatient services. There may be huge opportunities to improve flow, particularly if they adopt the culture of the ED in terms of ordering the test now, getting the results now, and acting on the results now.”
Dr. Viccellio also cited the drop in services on weekends, which can prolong hospitalizations. “We cannot continue to try to provide a five-day-a-week solution to a seven-day-a-week problem,” he said. (See FastLinks for Dr. Viccellio's EMN editorial on why inpatients services should be 24/7.)
Would instituting a time mandate do anything to alleviate this problem? Will it provide a way to manage current challenges to the ED? Will it solve crowding? Take, for example, the concept of reducing the time it takes to provide vital signs for every patient. “They may be completely unnecessary in some cases,” Dr. Viccellio said. “But I think you need to make a broad division between extremity complaints and symptoms related to the head, chest, or stomach. In the latter, vital signs may provide crucial information regarding how sick the patient actually is. Once you know the diagnosis, a smooth protocol is great.”
But any mandate in health care can have intended and unintended consequences. “We may know what the intended consequences are, but we need to know the unintended ones, too,” he said.
Dr. Weber said she didn't think the issue could be solved without mandates. “What that mandate is — well, that is another question,” she said.
Dr. Weber said she concluded that a strict length-of-stay mandate succeeds on many levels, but a strict cutoff for the length of stay is nonetheless a “blunt instrument” that must have room for flexibility.
What happened, for example, when a four-hour target for patients' door-to-discharge or admission was missed, even by minutes? Under the NHS system, no compelling reason required continuing the high-efficiency effort. “It didn't matter, in terms of the metric, whether it was five hours or six,” she said. Mandates that would incorporate incentives for time saved past the target could improve on the program, she suggested.
Dr. Zane said a mandate should not require that every patient is seen in a time frame, “like 10 minutes,” but he noted that emergency physicians need to accept that quality of performance is at least partly efficiency in delivery.
Another challenge is limiting the high variability that may be seen among health care providers. “We need to be more similar than different,” Dr. Zane said. Providers have different styles of care, he said, but some differences can be eliminated without affecting — and could even enhance — patient care by “protocolizing” certain conditions such as suspected MI and blunt force trauma. “This gets called cookbook medicine,” Dr. Zane said, “but I would say to the resistance of it, well, we have to change. We have to create solutions. We have a burning platform in the United States, and it is emergency care.”
His hospital, which is undergoing a huge construction effort in the ED, is moving from the kind of serial processing that has been done since the inception of the specialty to a parallel one, he explained. Building exceptional facilities is a big step forward, but any redesign needs to involve better processes, too, Dr. Zane said.
The NHS has dropped the mandate that was the focus of Dr. Weber's research in the short time since she left England. A new administration is in place, and party changes can mean swift reversals of previous programs, Dr. Weber explained.
Nevertheless, one of the benefits of this approach is that in most cases mandates induced the hospital to work closely with the ED. “I think it promoted cooperation. In fact, it imposed it, you could say. And both parts had to collaborate to meet the mandate. They didn't have a choice,” she said.
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- Read Dr. Peter Viccellio's EMN editorial, “Queueless or Clueless? Why Inpatient Services Should be 24/7,” at http://bit.ly/RCtAWX.
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