Exploring ED Solutions

In our May Intelligence Report, leaders listed their greatest challenges regarding their ED. HealthLeaders Media Council members discuss the biggest challenge they are facing and what approaches they are taking to address that.

This article first appeared in the November 2014 issue of HealthLeaders magazine.

Julie Dunlop, RN
BSN, MRO-A
Director of Emergency Preparedness
East Liverpool
(Ohio) City Hospital

One of our major problems is patient flow. We get a lot of patients who are underinsured or uninsured. We have a lot come because there are only two hospitals in the county. We sit where West Virginia, Pennsylvania, and Ohio meet. We get a lot of patients from all three states. We are a tiny ER. We have probably only 22 beds. Of those, only 10 are urgent care beds. The rest are fast-track. So we can get overwhelmed fast.

For workflow we use a lot more physician assistants. They see probably 60% of our patients. Right now we are going through a lot of restructuring, closing floors down because of the financial status of the community. We fly a lot of our patients out who need critical care because we just don't have the doctors available.

We also redesigned the whole system to make it faster. Our time to discharge is usually less than an hour unless it is an urgent patient, but we usually have them out of here in less than four hours or admitted upstairs. Once they are admitted we have a nurse assistant who will take patients up to the floor, if they don't need a cardiac monitor, while the nurse is giving a report.

Kyle Martin, MD
Medical Director for the Emergency Department,
St. Mary's Hospital
Madison, WI

Probably the trickiest balance we have been trying to find this year is rightsizing our nurse staffing. We wanted to have a nursing ratio that more closely matched our patient volume and demand. We actually downsized and as soon as we did that, of course, we found that our volumes went back up beyond what they had been budgeted for. We started to see changes in our metrics in terms of door-to-doc times and patient satisfaction.

As you downsize, your nurses become overworked and frustrated. We had a double-whammy crisis of downsizing combined with an exodus of nurses who then felt overworked, which then exacerbates the shortage even further.

We have made steps to right the ship. It is tricky because you could have your nurses at an appropriate four-to-one ratio and have eight more patients walk in and you are quickly overwhelmed. It's not like a surgery-and-procedure center where you know your scheduled caseload for the day. In the ER, you can let someone go home and 20 minutes later you've got a whole new influx of patients. That is the tricky part of being a leaner organization: having the appropriate ER staffing levels but also having the capacity to ramp up when you need to. Currently, we are quite happy with the balance we have achieved.

Alex M. Rosenau, DO, FACEP, CPE
Senior Vice Chair of Emergency Medicine
Lehigh Valley Health Network
Allentown, PA

The biggest challenge we have is throughput: when we are finished with our patient, having a place for that patient to go. There are deep-rooted causes for throughput problems, and their root causes will not be the same in every hospital. Some places are underbuilt. Other places have more processes and not enough hospitalists. In some places it's the reimbursement and the financial issues of an institution. In some places it may be the composition of the team in the ED. There is more than one set of causes. There is more than one set of solutions.

We do know the proper place to treat a patient is not a hallway. The patient is not in the hall because the ED is inadequate. The patient is in the hall because the facility response is inadequate. In most cases it is that the resources don't exist upstairs. Hospitals are still not built for seven-day-a-week care. Things are run differently on Saturdays and Sundays.

In many cases the C-suite is on the job. They have more data and wisdom than we give them credit for, but there are financial, budgetary, and planning issues that have to do with uncertainty in the changing reimbursement environment, and that has had a large effect on the ability of hospitals to expand their care.

Sue M. Cadwell, MSN, RN, NE-BP
Director of the ED Initiative
HCA
Nashville, TN

On the many challenges EDs face. The biggest challenges are a combination of all of those things [listed in the survey] because they all impact one another. We are trying to look at traditional ways of judging emergency department performance, such as metrics and throughput, and tying that to clinical quality that is specific to how the patient presents. We are trying to see if there are ways to take patients who present with some of the most common chief complaints and provide care faster, much like the industry did with STEMIs, for example.

On efficiencies and variables. There is no one answer for addressing all of the issues that impact EDs. At HCA, we have many hospitals that obviously have some commonality in the way they do things, but there are often some differences based on things like volume, physical layout, specialty care, and other variables.

On patient needs. The strategy has to be giving the patient exactly what he or she needs. In the past, some emergency departments have had processes that were designed to handle patients and emergency resources all the same way, without taking into consideration the acuity of the patient's presenting problem. Finding the right way to do things requires putting patients first. We want to be respectful of their time, but at the same time be certain caregivers are given enough time to do their best. The key is having EDs that use proven processes while allowing for tailored care that meets patients' needs.