Examine your emergency department, stat! ED is key to hospital reputation

Simple solutions make for satisfied patients

Your hospital might make it onto everyone’s Top 10 list for cancer treatment or cardiac care. You might have renowned orthopedic surgeons or an intensive care unit on the cutting edge. You might even have the best mother/baby unit around. But if your emergency department (ED) makes patients wait for hours on end, chances are they won’t care about all your other good points.

Think of the ED as the gateway to your hospital. That’s where most people in your community have their first contact with you, and fair or not, that’s where they develop their first and sometimes lasting impression. In this era of increasing managed care penetration and cutthroat competition, can you afford to be known as the hospital where waiting times are extraordinarily long and patience is extraordinarily short? More importantly, can you afford to continue losing precious minutes that could compromise patient care?

Hospitals around the country are taking a hard look at EDs and, in many cases, are finding simple solutions to reducing delays and improving patient care. The problem in this area is that there are few national standards, and there is not much written about it in the literature.

In this issue of Healthcare Benchmarks, we present case studies from four emergency departments that can help jump-start your benchmarking effort. One hospital has an amazing guarantee that patients will be seen in 15 minutes by a nurse or 30 minutes by a doctor or the visit is free. (See story, p. 18.) Another has slashed time to thrombolytic treatment for heart attack patients from just over an hour to less than 25 minutes. (See story, p. 16. ) Two other hospitals have climbed out of the pit of poor patient satisfaction scores by making changes you can replicate. (See story, p. 19.)

"Patient satisfaction is a major focus for emergency departments right now because they’re being made to look at it," says Linda Kosnik, RN, MSN, unit manager of the emergency department at Overlook Hospital in Summit, NJ, and co-chair of the Boston-based Institute for Healthcare Improvement’s emergency department collaborative. "The reason is that it’s something very easily understood by a board of directors, and it’s something that can be easily benchmarked across the country. Managed care companies tend to be attracted to that also. And in the emergency department more than any other place, patient satisfaction is directly related to waiting times. No matter how well you do clinically, they don’t really care if they have to wait for a long period of time. The longer they have to wait, the worse your service is as far as they’re concerned, regardless of whether you’re medically correct."

Sandy Pryor, BSN, supervisor of emergency services at Baptist Health in Little Rock, AR, agrees that clinical skills are necessary but they aren’t enough. "The ER is a volatile spot, and it’s the main access point for a lot of people. We see 36,000 patients a year, and the national average says each one will bring 3.2 people with them, so that’s 100,000 opportunities a year for people to have a perception of us," she says. "We’re no different than Nordstrom or Sears. People come here with expectations, and meeting them is key to our survival. That’s basic to staying in business."

Should your hospital start focusing on the emergency department? Yes, says emergency medicine guru Louis Graff, unless you’ve somehow escaped the increasing pressure from payers and patients who are demanding better utilization of resources and higher quality of care. "These are very interesting times in the emergency department," Graff says. "The emergency department in some ways is the same old ER, like the TV show, and in some ways is dramatically different." Graff is the associate director of emergency medicine at New Britain (CT) General Hospital; a spokesman for the Dallas-based American College of Emergency Physicians (ACEP); and a faculty member at both the University of Connecticut in Farmington and Yale University in New Haven, CT.

Finding a solution

What are some of the solutions you might consider? For starters, an observation unit is one trend that’s showing up in half of the hospitals around the country, Graff says. Such units are separate areas of six to 12 beds adjacent to the ED where patients whose symptoms make it unclear whether hospital admission is necessary can be observed for up to 12 hours.

"The old way of doing it was checking people out over two hours in the emergency department," Graff says. "We missed about 5% of acute myocardial infarctions, 15% to 20% of appendicitis, 40% of ectopic pregnancies. We admitted a lot of people to the hospital for extensive work-ups who ended up having nothing wrong with them. The average hospital admits about 60% of patients with chest pain who come to the emergency department, and about half turn out to have nothing wrong."

Observation units virtually eliminate the issue of missing key symptoms and decrease the admission rate to about 20%. Usually 5% to 7% of patients spend some time in the unit, and those patients tend to have higher satisfaction, Graff says. Patients who get the extra work-up in the observation unit generally feel more comfortable with the decision either to go home or get admitted. They feel as if the doctors and nurses are taking them seriously, and they’re happy to get the chance to avoid spending an unnecessary couple of days in the hospital, he says.

And not only does satisfaction increase, but costs decrease. A recent study1 from Cook County Hospital in Chicago found that using accelerated diagnostic protocols (ADP) in a chest pain observation unit cut the admission rate by more than half, with 45% of the ADP patients admitted compared to 100% of control subjects. The mean total cost per patient for ADP vs. control patients was $1528 vs. $2095. The mean length of stay for ADP vs. control patients was 33.1 hours vs. 44.8 hours.

Observation units are just one trendy process change; hospitals are looking at a variety of other structural ways to reduce delays and waits. "The major measure of whether patients are happy with the ED is how long they had to wait," Graff says.

Some are setting up walk-in areas exclusively for patients with minor problems, and others are providing stat laboratories where certain tests — urine, pregnancy, blood enzyme, throat culture — can be done right in the ED, Graff says. "For a lot of patients, the time spent waiting for test results to come back from the lab is a large part of their overall waiting time. If you can get that test time down, you can have a dramatic effect on your ED and on the satisfaction of your patients," he says. Reducing the length of stay keeps your costs down, too.

Another trend is specialization in certain areas such as chest pain, trauma, or pediatrics. The jury’s still out on whether that’s a good idea and on how to determine whether certain patients would receive better care at certain hospitals, Graff says. "It’s going away from the old idea that emergency departments should be able to do everything, to recognizing that every emergency department is not the same," he says. "The issue is how to do it without compromising the hospital’s ability to provide emergency care for its community."

At its last council meeting held in November in San Diego, ACEP passed a resolution to look at the issue of categorization of EDs by level of service. ACEP has also formed a task force on how technology will affect the ED of the future.

For more information on ACEP’s efforts, call (800) 798-1822 or write ACEP at P.O. Box 619911, Dallas, TX 75261-9911. ACEP’s Web address is: www.acep. org.


1. Roberts R, Zalenski R, Mensah E., et al. Costs of an emergency department-based accelerated diagnostic protocol vs. hospitalization in patients with chest pain. JAMA 1997; 278:1,670-1,676.