Change the "footprint" of wait areas, reduce lawsuits

It's safer for patients to wait on the "back end" of ED visit

To solve the problems that contributed to ED staff actions being considered as potentially criminal in recent cases of patient deaths in Los Angeles and Illinois, the answer doesn't lie in reducing risks of adverse events in patients kept waiting for hours, according to James J. Augustine, MD, FACEP, director of clinical operations for Canton, OH-based Emergency Medicine Physicians.

"I don't believe we should be working hard on establishing systems for doing reassessments," says Augustine. "We need to completely redo the greeting process, so that the patient is plugged in to treatment immediately," says Augustine.

Instead of performing and documenting repeat assessment during long waits, hoping that a patient's deteriorating condition won't be missed, the goal is for the patient to be dispositioned quickly so the next patient can be seen and treated, he says.

If the patient is going to be waiting at any point, they should be waiting only after they have received their initial evaluation and diagnostic tests, says Augustine.

"If you are going to create a waiting room, it should be at the end when all the testing is done and a few results haven't come back yet, and a further discussion needs to occur," he says.

Rethink waiting areas

The root cause of the recent highly publicized patient deaths which led to lawsuits and consideration of criminal charges, says Augustine, is that EDs are designed incorrectly.

"We have decided that we need to screen people in the front end and decides who needs to wait. I don't think that is fair, and I don't think it's the right way to structure the department," he says.

Augustine points to another area of the hospital with similar challenges to the ED-labor and delivery, and says they do a much better job of accommodating patients who come in unpredictable numbers. "When a woman comes in labor, they don't tell her to sit outside and wait for 12 to 24 hours," he says. "Somehow we have designed the ED so we can make people wait. And frankly in some cases, it's done with the idea that if we make them wait long enough maybe they will leave. That is tremendously unfair and leads to problems like what happened in these cases."

Two examples of approaches that have been shown to reduce liability risks are physician triage and team triage, says Augustine. Both these approaches aim to reduce barriers in the "front end," before a patient is seen by a physician.

"We need to make the front end a relatively small footprint in the process-just enough to know who needs to be seen in the ED, and then get them back," he says. By reducing the size of your waiting room and using the extra square footage for increased treatment space, you can "change the footprint" of your ED, says Augustine.

"You don't want to wait for a bad outcome and notoriety to make changes," he says. "You want to increase patient and staff satisfaction, and reduce the stress on the people who are otherwise out front trying to be the 'wall.' Those people have a very stressful job thinking about who should be going back and who shouldn't, when in fact everybody should be going back," says Augustine.

There is no surprise on any given day about when people are going to arrive and what services they are going to be needing, says Augustine. "It's fairly predictable in many EDs. They start arriving at 8 or 9 or 10 a.m., and stay at a constant flow until 8 or 9 or 10 in the evening," he says. "In labor and delivery, they receive patients, put them in a patient care area and begin to process them. That's the same thing we should be doing in the ED. Instead, we have fallen into a pattern where we think we need to have every patient triaged."