Volumes still grow, says survey of EDs

Managers see the trend continuing in 2010

[Editor's note: This article is the first in an ongoing series reviewing the latest findings of the Emergency Department Benchmarking Alliance (EDBA) and how ED managers are addressing the challenges that members have identified. This first article discusses how ED managers are combating steadily increasing volume. The EDBA for 2009 shows increases of 5%-10%. The EDBA findings are significant because they represent feedback from 376 high performing EDs serving 14.8 million patients in the calendar year 2009.]

The steady growth in ED volumes gives no indication of slowing down at Gaston Memorial Hospital in Charlotte, NC, according to Jayne Kendall, MD, FACEP, the ED's medical director.

"We were at 96,000 2008 and 104,000 in 2009," Kendall reports. "I would have thought it was due to H1N1, but it does not seem to be slowing down, and those cases are pretty much gone."

Her ED has had several months recently during which there were more than 9,000 visits, she says.

The situation is no different at Eisenhower Medical Center in Rancho Mirage, CA, although in their case it might be more of a "build it and they will come" situation. "We're up 15%-20%, but we built a new ED and opened in July 2009," says Euthym Kontaxis, MD, the ED's medical director. "Before that, we had been seeing 5% increases."

Some of the growth is due to the ED's success, Kontaxis says. "We have a nice new ED, and we're a preferred place to go," he says. "Part of the reason is that we've really improved door-to-doc times, which made it more attractive for people who may have had minor problems. Also, we've had a slight increase in population."

Kendall says she puts a physician in triage during the ED's busiest hours. "Our peak hours usually start around 2, and 8 is the time we start to see a slowdown, but we keep the physician in triage open until 10," she says. "You can't control having 20 people come all at once, but it does help when you make sure those patients get seen instead having everyone sitting in the waiting room wondering what's going on."

Hospitalists come down to see the patients within 30 minutes, says Kendall. "And since our nurses are incentivized to get patients upstairs 30 minutes after the orders are on the chart [they get publicly recognized at meetings], we do not really have people boarding."

Keeping things flexible

Kontaxis faces a different sort of challenge. His ED is in a resort community with significant seasonal fluctuations.

"We have flex staffing and tell the doctors to take their vacations in the summer," he says. Every month, Kontaxis looks at past history to get an idea of where he is headed in terms of census and then determines how the ED will be staffed for the next two months.

"We have gone to a back-up situation where we can call doctors in if need be," he says. "We have shorter shifts during the busy seasons, but we have few more of them." Even that is flexible, Kontaxis adds. Seven- or eight-hour shifts can be extended an hour or two if need be.

The staff is fine with that arrangement, he says. "They're aware of the situation, and we all try to work together," Kontaxis explains. So, he says, shifts build to volume peaks and then come down. Shifts and nurses go an hour or two more or less depending on how many patients are coming in. Doctors sometimes come in at noon, other times at 1 p.m., still others at 11 a.m. "In the summer, people tend to come in later, so we move [the extra hours] to evening," Kontaxis says.

Like Kendall, Kontaxis will put a doctor in triage if the ED begins to hold patients. He also takes a long-range approach to dealing with volume growth. "We study demographics," Kontaxis says. "For example, we talk with the Chamber of Commerce and other people in the hospital about what growth they are anticipating."

Sources

For more information on dealing with growing volume, contact:

  • Jayne Kendall, MD, FACEP, Medical Director, Gaston Memorial Hospital, Charlotte, NC. Phone: (704) 834-4053.
  • Euthym Kontaxis, MD, Medical Director, Eisenhower Medical Center, Rancho Mirage, CA. Phone: (760) 773-1221.

EDBA database is 'independent'

The database maintained by the Emergency Department Benchmarking Alliance (EDBA) is "an independent, unbiased database of demographic and performance metrics," says Charles L. Reese IV, MD, FACEP, chair of the Department of Emergency Medicine at Christiana Care Health System in Newark, DE, and president of EDBA. Because it "is created by the membership, for the use of the membership, and has no commercial interest attached to it," he says, data such as ED volume growth trends are particularly "clean."

Membership in EDBA requires that participating members submit performance data on a yearly basis, Reese explains. In return, members have access to the database. "ED managers across the country tend to share similar problems and interests, and in essence speak a common language which is not understood well by those outside the specialty," Reese notes. "One of the best parts of EDBA membership is being connected to others within this world, and being connected with new skill sets and concepts which can help address these specific issues." For more information, contact Reese at phone: (302) 733-1840. E-mail: creese@christianacare.org.


Clinical Tip

Is waiting for labs always necessary?

When your ED is being slammed, waiting for lab results might not always be necessary, says Jayne Kendall, MD, FACEP, medical director of the ED at Gaston Memorial Hospital in Charlotte, NC.

"For me, when you're really busy, you do not have to wait for all labs," Kendall says. "If you have an 80-year-old patient with chest pain, they are still going to be admitted, so just call and get the orders on the chart. You know what the final disposition will be regardless of what the labs are."

This approach helps keep things moving when your department experiences high volumes, she says.


Having surge plan for staff essential

No matter how much staff you have available to deal with high volume, it's vital to have a surge plan in place to provide optimal care.

"EDs are frequently under-planned," says Euthym Kontaxis, MD the medical director of the ED at Eisenhower Medical Center in Rancho Mirage, CA. "Everyone says 'We'll just deal with it,' but if you do not give your staff structure, they often can't do it."

Every ED has some A players, who will always know what to do, Kontaxis says. "But you will have some B and C players, and they need a framework," he says.