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Fixing ED throughput is important—but is it enough?

Nearly every hospital, at one time or another, will suffer from emergency-department overcrowding. At any given moment, in fact, half of all U.S. hospitals report running an ED at or above maximum capacity.

There’s no mystery as to why. The unique dynamics of emergency care—high volumes, complex cases, variable acuity, unpredictable admission patterns, 24/7 operational schedules—make ED patient flow one of healthcare’s most intractable problems.

It’s also, however, an important problem to solve. Communities invest an enormous amount of trust in their hospitals’ emergency departments.  They rightly expect that EDs will provide timely and appropriate care to all comers.

To live up to that mandate, it’s incumbent on health-system leaders to consider the root causes of poor patient flow, and implement strategies to solve it.

Fortunately, trailblazing organizations have already discovered a few helpful strategies.

This post will explore what the research shows about patient flow, which interventions have strong evidence in their favor, and what it took for two NRC Health customers—Houston Methodist Willowbrook Hospital and Tucson Medical Center—to put these interventions into practice.

The high stakes of poor patient flow

First, it’s important to count overcrowding’s costs. The consequences of an ED with poor patient flow tend to cascade, undermining hospitals’ operations in several ways.

The most obvious of these is lengthy wait-times. Long waits in emergency rooms are so ubiquitous that they’re now almost a cliché.

NRC Health data bears this out. In 2018, NRC Health’s Real-time feedback platform used natural language processing to analyze 1.4 million patient comments. Perhaps the least surprising finding is that patients don’t like waiting too long for care. 77% of all comments about hospital wait-times were strongly negative.

At any level of care, this should be cause for concern. For EDs, long wait-times are particularly disastrous, and emergency patients frequently translate their dissatisfaction into action. Every year, long wait-times lead 2% of ED patients to walk out before they’re ever seen by a clinician.

Not only does this imply an immediate loss of potential revenue, but also an incalculable loss of community trust.

As Mimi Coomier, Chief Nursing Officer at Tucson Medical Center, put it: “There is no question that patients who leave our ED without being seen have a financial impact on our organization. And we shudder to think what it does to our reputation.”

Still worse are the clinical implications of ED overcrowding. Overfull emergency departments are associated with poor quality of pain care, avoidable delays in treatment for heart-attacks and pneumonia, and, ultimately, with increased ED mortality.

Effective interventions

These manifold consequences underscore the urgency to limit ED overcrowding and improve patient flow. Academic research suggests the effectiveness of a handful of tactics.

Doctor-directed triage, for instance, has been shown to substantially reduce patient wait-times and improve patient flow.

Co-locating primary-care physicians in emergency departments expedites the treatment of non-urgent cases and reduces ED utilization rates.

Point-of-care-testing (POCT), when used judiciously, improves the rate of timely patient discharge, reduces delays in treatment, and speeds up the work of triage.

In concert with these strategies, the emergency departments at Tucson Medical Center (TMC) and Houston Methodist Willowbrook Hospital (Willowbrook) tried some other techniques that focused on middle-acuity patients—and that proved extraordinarily helpful.

TMC’s streaming protocol

With an otherwise outstanding reputation in the Tucson community, TMC fielded many patient complaints about ED wait-times.

That’s why, in 2017, TMC deployed a unique streaming process, developing a specific assessment procedure for when patients present with a Level 3 on the ESI scale.

By focusing their attention on this sub-population, TMC saw an enormous improvement in ED throughput, connecting these patients to necessary hospital resources much faster than before. Even better, moving Level 3 patients through the system also freed up valuable staff time to attend to more emergent cases.

Willowbrook’s Results Pending Area

Willowbrook’s ED also suffered from lengthy delays in the emergency department. In response to that, the ED’s nurse manager, Heather Cofer, coined a mantra: “We’re going to keep ambulatory patients ambulatory!”

To that end, she and Willowbrook’s other ED staff devised a Results Pending Area, where patients could go to await lab results after being examined. It’s a comfortable space, with 12 lounge chairs (with IV poles attached) and big-screen TVs throughout.

Ambulatory patients loved the space. But more than that, it gave these patients a place to go, freeing up exam-rooms for further patient intake. This allowed Willowbrook’s staff to see a much higher daily volume of patients.

Lingering confusion

However, both TMC and Willowbrook were to discover that, while these initiatives drastically reduced wait-times, they didn’t necessarily improve patient satisfaction.

The problem was that each change in the ED in-flow process introduced new complexities to patients’ journeys. Often, the extra steps left patients feeling confused.

NRC Health’s Real-time feedback revealed as much to TMC’s leaders, who found that patient comments frequently reported a sense of disorientation.

Likewise, at Willowbrook, NRC Health’s satisfaction surveys discovered that ED patients felt a lack of coherence in their care. As a result, overall satisfaction with ED care encounters hovered at just 55%.

Communication is key

While not necessarily welcome news, the feedback helped both TMC’s and Willowbrook’s leaders re-envision their efforts.

“Real-time feedback really helped us take a step back and truly look at the initiative from the patients’ perspective, not our own,” said Cynthia Carsten, TMC’s director of patient care services.

TMC was able to re-tool their assessment process to keep patients feeling like they were in the loop. Reports of confusion and frustration declined right away, and TMC saw a rapid uptick in their NRC Health Loyalty Index Score—one that put them comfortably above local competitors.

Willowbrook, meanwhile, focused on a more interpersonal approach. They trained staff to systematically narrate patient care, making it eminently clear to patients where they stood in the process.

“We as clinicians know what’s going on, but patients don’t have our training or our expertise,” Cofer said. “It’s a responsibility we have, to explain what we’re going to do with them.”

The narration process worked. At Willowbrook, satisfaction with nurse and physician communication shot up almost 15%, from 61.7% positive in October 2017 to 76.4% in September 2018. And in the same period, overall satisfaction went from 55.6% to 77.6%.

Never neglect the personal

The cases of TMC and Willowbrook prove that, while resolving the ED’s logistical hang-ups is crucial, it will not be sufficient to keep patients satisfied.

Patients don’t gauge their care encounters by objective metrics alone. Concerns like minutes-to-treatment or time-to-discharge are important to them—but not paramount.

What matters more to patients is having a sense the sense of being involved in their care, of feeling well cared for, of having had a personal experience with medicine.

No doubt, bringing that level of personalization into the ED is one of healthcare’s most daunting challenges. Fortunately, both of these institutions are happy to share their expertise.

This case study reveals the specifics behind TMC’s successful ED interventions. And this article spells out precisely what it took for Willowbrook to reform their ED care experience.

We hope their examples are as instructive as they are inspiring.