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Patient drives truck into ED after complaining about wait
Incident shows potential dangers of unseen patients' frustration
On Wednesday evening, Oct. 24, 2007, a man drove his pickup truck into the exterior wall of the ED at the Medical Center of Central Georgia in Macon. A patient of the ED told the local press that the man, also a patient, had conversed with him over the five-hour wait and left after complaining about the wait.1
Since the driver also had told the witness that he was there to be seen about back pain and seizures, it was unclear whether the crash was deliberate or the man had just been trying to drive away in frustration when he seized. The hospital would not provide any medical details, citing confidentiality issues.
In either event, the incident demonstrates the potential anger and frustration by patients who face long waits, and it offers a frightening example of what potentially can happen when such a patient leaves without treatment.
"When patients wait to be seen, it is one of the biggest dissatisfiers," notes Paul Culler, MD, medical director of the ED at Marion (OH) General Hospital. "I think in many smaller markets [such as Macon], the expectation is that there will be shorter waits."
If patients become frustrated and leave and subsequently experience an adverse outcome, this outcome can be a huge liability issue as well as a customer service issue, Culler says. How does he seek to minimize the likelihood of such an event? "Specific to this story, you have to know your audience and the community in which you are practicing," he says. Marion General always encourages physicians to live locally, so members of the community see medical staff members in social situations, Culler says. "Over the course of time, this really helps, because the community sees medical staff members out in social situations." In addition, he says, the staff can gain an understanding of community expectations.
In a larger urban community, says Culler, patients might be used to six- or eight-hour waits. "Here, that would never fly," he says. "Two hours is considered a long period of time."
Advance planning can help minimize the likelihood that patients will face long waits and leave in frustration, says Culler. "The ED staff must be in tune and understand ahead of time what to do," he says. "There is a lot of preparation and planning that goes into the management of the department when it is packed to the gills."
What does that planning entail? "Consider staffing patterns that match department demand," he advises. "You really have to know how many patients arrive on average each hour of the day and night, so you can be as fully staffed as you can in peak periods." This strategy calls for a significant amount of strategic planning by everyone from the staff nurse to the lab, he says.
Despite the best of plans, however, "things happen," Culler concedes. At that point, he says, there are other strategies that come into play.
"Hall beds have become an accepted standard, and there are times where we use a call-in system to bring in an extra provider," he says. "We also have a couple of makeshift rooms — not within the department, but off the lobby." One of the rooms serves as a secondary triage area, and another can be cordoned off to create an additional treatment room. They try to "skim off" the lower acuity patients in the lobby, so they can be served adequately without using a critical bed in the department, Culler explains. "We bring them back to the makeshift room," he says. "They may just need an ankle X-ray or medication for a sore throat."
When all else fails . . .
Despite all best efforts, no system is perfect, and patients sometimes will become frustrated and angry with their wait time. What do ED managers do in such situations? The most important things are to continue to communicate with the patient and let them know the reasons for the delay, says Deb Richey, MPA, director of emergency services at Parkview Hospital in Fort Wayne, IN.
Richey says despite the fact that long waits are rare in her department, her nurses are trained to deal with such situations. "It's just not good if you ignore patients and wait until they become angry," she says, "and it's important as part of orientation that we teach nurses how to respond and how to set reasonable expectations."
It's just as important to teach staff what not to say, as it is to teach them what to say, Richey says. "We try to make sure the staff understands that they want to avoid saying things like 'I'll be back in a second,' or 'The doctor will be there in a minute,' if that is not what normally happens," she says. "Let them know how long it takes on average, and then try to exceed their expectations."
Not everyone will walk away pleased, adds Luis Eljiek, MD, FACEP , FAAEM, medical director of the ED at Potomac Hospital in Woodbridge, VA. Eljiek recommends that whatever the patient's complaint is, listen to it. "Don't put it off and say you have other patients to see and you'll see them in 15 minutes; that will heat them up even more," he advises. "Be an active listener, offer reasonable solutions if possible, but at least acknowledge the fact that you have listened to their concerns."
The nursing staff at Potomac takes a course in crisis prevention intervention from the Crisis Prevention Institute in Brookfield, WI, says Inez Johnson, RN, BSN, clinical director of the ED. "It's an eight-hour course that helps you to understand the behaviors you are seeing and respond appropriately so they don't escalate," she explains.
Your staff also need to be trained in what Culler calls "service recovery" techniques. "This is not rocket science," he says. "It really helps to look people in the eye and be as honest as you can."
It's also important that patients understand your triage system, says Culler. "Signage is a big thing; you can use it to help explain we take the sicker people first — but signage without an explanation can only go so far," he admits.
Still, Culler concedes, "There are times when a patient might say, 'I don't care if there are two people having heart attacks; I want to be seen now.'"
In preparation of such eventualities, ED staff should be taught that they can seek help with an unhappy patient by pushing things "up the chain of command," says Richey. "Something we frequently do is whenever we identify a patient who is not happy, we will try to enlist a team leader or a charge nurse to intervene, because many times if a patient knows this is going up the chain of command, it helps alleviate their stress," she says. "If that does not work, they may call a house supervisor or one of the ED managers."
Occasionally, you will get angry patients or visitors who will make threats, Richey says. "It's important in such a case that the nursing staff alerts security or the police," she says. "It's not OK for people to make threats."
For more information on dealing with frustrated and angry patients, contact:
For more information on crisis prevention courses, contact: Mary Burk, The Crisis Prevention Institute, Brookfield, WI. Phone: (800) 558-8976. E-mail: email@example.com. A one-day program is $399 per person; a two-day workshop is $779 per person; and the four-day instructor certification program is $1,239 per person.