Emergency Expectations

In our May 2015 Intelligence Report, healthcare leaders cited a variety of concerns related to the emergency department in the coming three years. HealthLeaders Media Council members discuss their expectations.

This article first appeared in the November 2015 issue of HealthLeaders magazine.

Timothy Greco, MD
Medical Director of Emergency Services
St. Jude Medical Center
Fullerton, CA

We have a good triage team, but we're trying to make it even more efficient. The hope is to combine a simpler protocol for triage and simplify the exhaustive and long intake questionnaire that currently serves as initial welcome.

We've recently hired on a team of consultants to help us with metrics and building new efficiencies into our intake and triage process.

I'd say that the best "technology" in the ER right now is actually people who can do nonphysician things for the physician.

Scribes have been a big plus. The electronic medical record is still something that is alien to many of us. I think that while most doctors are fairly computer savvy, many are still not comfortable with EMRs.

We're also developing workers who will manage patient placement. Placing alcoholics, drug addicts, or psych patients after a hospital stay, or placing older people in nursing homes takes a ridiculous amount of time. We're also trying to bring in individuals who help manage patients for the physician. This person will be tracking when the patient is ready to be seen, if the patient got in to a bed, and so on. These are all things physicians don't do very well, and that takes them away from their clinical goals.

Lou Hochheiser, MD
CEO
St. John's Medical Center
Jackson, WY

Our hospital is situated in a rural area, but we have as many as 3 million travelers come through the area every summer on the way to visit the national parks, including Grand Teton and Yellowstone. The greatest challenge associated with being in an area with a large transient or seasonal population is the lack of predictability.

We never know what kind of volume we're going to experience in our emergency department. If a new, dangerous bike path is opened or if we have thunderstorms on the mountain while people are climbing, we can have a sudden, unexpected increase in volume.

Accidents are our emergency department's greatest cause of bottlenecks. A couple years ago there was a lightning strike on top of the mountain that brought 17 people in with injuries resulting from it. But one of the benefits of being a hospital in a small, rural community is that, frequently, our staff finds out about emergencies and comes in to help out, even if they're not on call.

One of the other challenges we have is that more and more tourists are visiting from foreign countries. Last year, we had a bus overturn in a nearby national park. We ended up with 27 Mandarin Chinese speakers. We dealt with the incident with the help of local members of our community who spoke Mandarin—and a lot of gesturing.

David Usher
Chief Financial Officer
Coteau des Prairies Health System
Sisseton, SD

As a critical access hospital, our challenges are generally the same as everybody else's, except that we don't have economies of scale. I can go two days and not see a single patient in the ED, then I'm here on a Friday night and we get 20 patients, one right after the other. It makes staffing an absolutely unknown level of requirement, and it's really quite difficult.

We're currently considering going to a model that focuses on employing paramedics rather than nurses, as they're easier to staff and equally talented. I believe that moving to paramedic providers will help increase efficiency. I can train paramedics quickly, there are more of them available than other health professionals, and their scope of practice is quite wide, especially in emergency situations.

Developments in telemedicine have been immense for us. Telemedicine links us with major trauma centers and allows us to move forward with telepsychology, telepsychiatry, remote substance abuse counseling, and other important issues we run into here that we're just not equipped to cope with. Telemedicine technology is proving to be very necessary to us.

Pamela J. Stoyanoff
Executive Vice President and Chief Operating Officer
Methodist Health System
Dallas, TX

On ED bottlenecks: We are definitely experiencing significant increases in ED traffic. If I look at our emergency visit volume from the current fiscal year and compare it against last year, it has grown by almost 11%, and we have no reason to believe that will decline.

To handle this rise, we have increased our ED footprint to serve more patients at three of our four campuses. The fourth campus is landlocked, and there's nowhere we can expand to. Instead, we are building more ICU rooms within our patient tower so we can move patients to critical care sooner, which should free up space in the ED.

On ED staff retention: High nurse and technician turnover in our EDs has been a significant obstacle for us. I wouldn't say that we need to expand these positions or change our ED staff composition; we just need to fill and retain the positions we already have. If we can fill our current vacancies, we'd be staffed effectively.

It's very difficult to keep the ED staff engaged—it's a rough place to work. We're trying to determine strategies to retain staff, including retention bonuses and other efforts to try to keep staff on board once they get here, but it often feels like they leave as soon as we hire them. Often, it feels like a "churn and burn" scenario.