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Special Report: Taming the Crowding Beast

Scheck, Anne

doi: 10.1097/01.EEM.0000427049.04611.41
Special Report


Is it time to tame crowding with timely crowd-sourcing? Emergency departments, along with sports venues and rock concerts, have discovered the power of the Internet for transmitting full capacity, which is just the kind of knowledge that is helping health care consumers make up-to-the-minute decisions. And it's just one of the ways that the year ahead may prove to be a turning point for helping to control surge periods in EDs.

Emergency medicine has its own name for the concept: crowd-informing. It's one of the “Big Cs” now appearing in the medical literature, part of a trio aimed at helping to mitigate crowding.

Crowd-informing now includes patient-friendly Internet postings by EDs, including use of mobile technology for check-in and “load balancing.” The other two Cs — cultural change and conversion — have been around for quite some time, but new examples are springing up, thanks to institutions such as Chicago's Cook County Health and Hospitals System. EDs across the country are finding ways to counter the increase in patient load, as even more people turn to the ED for health care.

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Walk down the corridor of Park Plaza Hospital on a warm Houston afternoon after exiting the parking area, and you will see a sign informing all passersby they can make an appointment in the ED. That same option is available at many hospitals now as a result of a program called InQuicker. It allows prospective patients to go online and find an available time spot and book it for a fee ranging from about $15 to $25. If someone who signed up isn't seen within 15 minutes of that allotted time, the patient gets the upfront money back.

But it isn't just convenience that is being sought by users, it is knowledge of wait times, some studies have suggested. (Internat J Emerg Med 2011;4:29.) Canadian researchers have shown in two recent studies that publishing wait times leads many patients to select the ED with the shortest waits, even when the ED is farther away. The lead investigator, Bin Xie, PhD, said it remains to be seen why posted wait times have such an impact, but it seems reasonable to believe that some patients may base their decisions entirely on a belief that the difference in wait times outweighs the difference in travel time.

“The difference in travel time would be less than 30 minutes, as the distance between the two hospitals is only six miles,” said Dr. Xie, an assistant professor of epidemiology and biostatics at the University of Western Ontario in London, Canada. “The difference in published wait times can easily be two hours or more, so it makes sense that some patients would do that,” he said.

Wait times can influence ED preference, but if time ceases to be an issue, customer loyalty seems to prevail among some patients. (CJEM 2012;14[4]:233.) Dr. Xie and colleagues found in a separate study that about 13 percent of 1,200 patients said they would stick with the ED to which they had become accustomed. “So we expect that at least some patients would be loyal to an ED if the wait time is no longer an issue,” he said, adding that he recommended that most EDs publish wait times.

“A good analogy is the lines at grocery stores. When customers can pick a line based on how many people are already waiting, the wait times at the lines tend to be roughly equal,” Dr. Xie said. “This would not be the case if customers cannot see the number of people already waiting in a line. In that case, there could be lines that are lengthy while others are short. This could be alleviated simply allowing customers to see how long the lines are and choose accordingly.”

Perhaps not surprisingly, younger people seem to use the wait-time data more often than older patients. Another team of Canadian investigators determined that ED arrival rates were the most useful metric for predicting ED busy-ness. (J Public Health Informatics 2011;3[2]:1; see FastLinks.) Crowd-informing offers a plausible, if partial, solution.

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Volume went up but wait times went down at John H. Stroger Jr. Hospital's ED in Chicago. How could this be the case? After all, patient numbers have grown significantly over the past few years, by between six and eight percent. Yet the Chicago ED cut its waiting time nearly in half over the past couple of years, to less than two hours on average.

“That is still too long as far as I am concerned,” though it is a substantial improvement, said Jeffrey Schaider, MD, the chair of emergency medicine for the Cook County Health and Hospital System and a professor of emergency medicine at Rush Medical College.

The hospital embarked aggressively on plans to convert to faster, more efficient “front-end changes, ED changes, and back-end changes” to obtain those gains, he said.

Part of that involved creating “Dr. Quick,” a concept that allows for faster assessment of patients who arrive by ambulance and from the clinic. “The initial workup is started in the triage area when there are no stretcher spaces in the back, and then the patients are moved to the clinical area,” Dr. Schaider explained.

“Dr. Quick” also sees all electrocardiograms to decrease door-to-balloon times, and sees and treats low-acuity patients rapidly “so they do not clog up the back of the ED.” The triage and registration process was also streamlined, with bedside registration, if necessary.

And a no-empty-beds policy was initiated, which requires patients to be moved immediately to any empty bed if one is available, he said. “We developed an action plan to admit patients to less traditional areas of the hospital depending of the level of the bed backup,” Dr. Schaider said. That meant the hospital in its entirety made an effort to reduce the amount of hospital crowding to move inpatients out of the ED more rapidly.

“They have reduced the number of long-stay patients,” he said. “Still, hospital overcrowding remains the Achilles heel of the ED,” he said. “If we cannot get the admitted patients out of the ED, then we cannot make any improvements.” (See sidebar.)

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Cultural Change

What else lies ahead? The seven-day hospital, hopefully, said Sandra Schneider MD, a professor of emergency medicine at the University of Rochester (NY) Medical Center. Already some hospitals employ a six-day work week, where the time-honored skeleton crew has given way to a fuller staff on Saturdays, she pointed out. This has advantages for the current health care workforce: working parents have a day off during the week for dental appointments, pediatric visits, and school volunteerism. “Or if you are like me, you really like grocery shopping in a store with practically no other customers,” she said.

But changing longstanding traditions, such as the five-day work week for personnel outside of the 24/7 emergency care staff, can be very challenging, or, as some in emergency medicine have put it, the furthest thing from possible. (See FastLinks for EMN's article, “The 24/7 ED in the 9–5 Hospital” and Dr. Peter Viccellio's EMN editorial, “Queueless or Clueless? Why Inpatient Services Should be 24/7.”)

Dr. Schneider, who lectures frequently on ED issues, often addresses successful ways in which crowding has been contained by EDs. One hospital administrator asked her after one such lecture, “What is the right number of boarders in the ED?”

“I said zero,” Dr. Schneider said. “Then he said, 'No, seriously, what is the appropriate number?' And again, I said zero,” she said. The administrator stalked off, but the incident didn't surprise her, Dr. Schneider said; boarding has become a part of the hospital culture.

Nearly 10 years ago, specific factors that inhibit cultural change in hospitals were examined in California Management Review by two investigators who sought to answer why hospitals seem so stymied when trying to rectify inefficiencies. Some of the findings sound current today: the ability of creative employees to do work-arounds that may end up making a problem seem less urgent by offering an immediate, if temporary, solution (that then becomes entrenched), and managers or directors who get great marks as good listeners, enabling psychologically healthy venting to occur rather than stifling it.

But without engaging in boundary-crossing that involves seeking direct action, an empathic supervisor may help sustain morale without addressing the underlying problem that's encroaching on it. In emergency medicine where problem-solving is held in high regard and team spirit is seen as tantamount to a can-do attitude, these attributes may mean staff members are relatively capable of coping with hardship in the work environment, prolonging the path to change.

Younger physicians are also eschewing the work hours of their predecessors, according to several anecdotal reports, including one in the New York Times this past spring that featured a newly graduated physician who chose emergency medicine over private practice because of the hours. (“More Physicians Say No to Endless Workdays,” April 1, 2011; see FastLinks.)

Rapid intake units also have meant much faster processing in many cases — five minutes or less in some places — making needed beds available in record time. Yet, gridlock persists, Dr. Schneider said. “There are financial incentives that will — and are — making hospitals smaller, not larger,” she stressed. For every situation in which boarding is improving, there are places in which it is getting worse, she noted.

External forces will propel change if an intrinsic cultural shift doesn't take place, Dr. Schneider predicted. This year, the Joint Commission will begin assessing ED stays of more than four hours, and patients kept longer than that will trigger an inquiry in some cases. Meanwhile, the Centers for Medicare and Medicaid Services will require reporting average lengths of stay in the ED.

The United States is the only one among nations like it that doesn't have requisite time-rule quality measures, she said. The time to be seen, and either discharged or admitted, is six hours in Australia and New Zealand, which seems a reasonable goal for American EDs, Dr. Schneider said.

Click and Connect! Access the links in EMN by reading this issue on our website or in our iPad app, both available on

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Stroger's Formula for Reducing Wait Times

The average wait time to see an emergency physician at John H. Stroger Jr. Hospital in in Cook County's busiest ED plummeted to less than two hours, and patients who left without being seen dropped by about a third, to about eight percent of the patient load. How did they do it at a time when there were more ED visits than ever? Jeffrey Schaider, MD, the chair of emergency medicine, said specific ED changes helped make the switch.

Reduced lab delays. The ED changed the process for sending lab tests so they are easily identified by colored sticker in the lab, and it transferred the responsibility to the nurse rather than the lab tech for tubing the blood work for the lab, which cut out one person from the process.

Initiated complete electronic physician order entry for medications. This reduced the time for the nurses to receive the orders, and it is easier to document the medications as being given.

Installed an additional ED CT scanner. This doubled the number of CT scanners, which reduced delays for the test.

Transitioned to an EMR for all of the patients. Stroger now has a paperless ED. — Anne Scheck

© 2013 Lippincott Williams & Wilkins, Inc.