By Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA, Special to AHC Media
Never have patient flow issues been as important as when you or a family member are the patient and the ED you choose to visit is completely oblivious to maximizing provider efficiency, improving patient flow, and providing good care. After many, many years of my involvement in the emergency medicine specialty, I thought the days of not seeing a provider for hours after arrival, having orders finally given but ignored by nursing staff, and nurses refusing to meet the eyes of patients standing in the doorway after hours of waiting to see a provider were well behind us. Turns out I was wrong!
For those of us "in the family" of emergency medicine, we generally have a luxury few of our ED patients enjoy. When we need emergency care, we visit a nearby ED where we know everybody or, at least, are known by someone on staff. We are treated with care and respect and generally leave feeling better. The real test comes when we are visiting another town, don't know the local EDs or providers, and end up in a dysfunctional ED facing what so many ED patients write to the local newspaper about: endless waits to get a bed, even when arriving by ambulance; an endless wait to see a provider; and followed by another endless wait to get basic testing completed. Then, and only then, is there a brief visit by a physician and, if you are lucky, an actual discussion with the doctor of where we go from here (e.g., upstairs, observation, or home).
As a result of my husband's current battle with cancer, we have seen a lot of our nation's health care system. Much of it functions exceptionally, especially the specialty clinics and hospitals geared up to manage special problems with special solutions. However, our recent visit to an emergency department in one of our nation's top hospitals has us wondering why some hospitals are making good decisions and others are making very poor ones when it comes to ED staffing, patient flow, and caring about the patient.
We've all heard the horror stories, so I won't go into detail, but when I became that person who personally removed the IV and helped my family member elope or LWOT, I believe it made me a co-conspirator eloper, and an entirely new world of concern opened up to me.
Nothing is more frustrating to a patient than to look across an ED, see empty rooms but standing-room-only waiting areas with obviously sick patients, see ambulance patients "on the wall," and all staff tapping away on computers, either oblivious, unconcerned, or unmotivated. Maybe all three. Nobody looks up, nobody acknowledges the patients or ambulance attendants. In other words, "GO AWAY" is the message.
ED flow is, in general, predictably unpredictable during certain days, times of days, and seasons. Staffing needs are, in general, predictable with the right data. ED staff''s good days and bad days are, in general predictable - we are all human. However, what shouldn't be acceptable in any emergency department is an attitude that nursing and provider staff needs (filling out electronic data rather than going to see a new patient, talking socially in earshot of patients, being in no rush to discharge a patient to empty a room for a new patient) should be prioritized over the needs of the patient. When caregivers refuse to provide comfort and care to their patients, it's time to hang up the stethoscope.
Hospitals like the one I experienced need to do a better job of developing culture change in their emergency departments, to ensure as best as possible that metrics are important (door-to-doc, throughput time, patient satisfaction, patient safety); that staff are caring and motivated, not just technically skilled medical care nurses and providers.
To develop and implement culture change, these hospitals will need a total commitment from the hospital C-suite, the nursing leadership of the hospital and the ED, and the physician leadership of the ED group and its medical director as well as some of the medical staff leadership. While culture change takes time, patience, and unwavering commitment, it is well worth it. A better working environment will lead to better staff retention, better nurse-doctor collaboration, and happier patients.
"Front-end" operations are critical areas of focus. Elements of well-managed ED front-end solutions should include consideration for immediate bedding, bedside registration, advanced triage (triage-based care) protocols, physician/practitioner at triage, dedicated "fast track" service line, tracking systems and whiteboards, wireless communication devices, kiosk self-check-in, and personal health record technology ("smart cards"). All of these are currently receiving considerable attention in the ED media and can be considered as potential solutions to streamline the front-end processing of ED patients. Though not necessary every day, these are potential solutions that become crucial during periods of significant capacity, overcrowding, and patient surges - guaranteed during the flu season but increasingly troublesome as ED volumes continue to climb.
The solution will be unique to your ED, but the investigation into how your ED currently functions, the identification of problem areas, the routine gathering of critical data about your ED operations, and your commitment to quality and meaningful interactions with your patients will determine which path you choose.