stethoscope 27 December, 2013

Long waits at Emergency Departments unnecessary

Using simple methods, Emergency Department physician Jody Crane and his colleagues drastically reduced waiting times at Mary Washington Hospital in Fredericksburg, Virginia USA. Now, the ideas Dr Crane and his team developed are being spread to the Swedish healthcare system.

These ideas came out of a difficult situation in 2003 at Mary Washington Hospital when waiting times were so long that over 14% of all patients entering the Emergency Department chose to leave before even seeing a doctor.

Dr Crane, was department manager for some 20 other physicians plus additional personnel, and came to understand the problem was caused by circumstances where the emergency department became a bottleneck in hospital operations. For example, one evening at the end of 2003, all of 44 beds in the 50 emergency bed facility were occupied by patients simply waiting for transfer to other departments at the hospital. This left only the 6 remaining beds for personnel to actually treat new patients – while 75 people sat in the waiting room.

To address situations like this, Dr Crane and his team introduced ideas based on LEAN production methods to develop their idea of ‘No Wait ED’. Emergency departments have advanced working processes designed for patients with acute or critical medical conditions. But Dr Crane understood that many of the patients coming to their emergency department were not actually in need of emergency medical care. The simple change in this regard was to treat these patients as at a typical outpatient clinic – quickly diagnosing their condition, treating if necessary, and then either discharging them or transferring them to other care departments in the hospital.

The next step was to establish a larger interdisciplinary group of medical personnel to create a more flexible system for patients with acute conditions. Their solution was designated ‘Rapid Assessment, Treatment, and Efficient Disposition’ based on the idea that people who really need emergency assistance must see a doctor or nurse within 15 minutes. Any long waiting should only take place after assessment by physician, a preliminary treatment determination, and any necessary testing was ordered with treatment initiated.

These simple changes enabled Mary Washington Hospital to reverse the trend towards longer waiting times at the emergency department. An assessment of the system conducted in 2009 found that the share of patients leaving the ED before seeing a physician went from 14% in 2003 to only 2%. This decrease occurred despite the general increase of patients from 72,000 to over 100,000 annually over the same period. The ED, using their improved procedures could treat patients in less than three hours on average compared to over four hours previously. Another measure showed that patient satisfaction increased significantly after these changes were introduced.

Similar experiences have been shown in Sweden, where Statens Beredning för Medicinsk Utvärdering (SBU, the Swedish Council for Health Technology Assessment) has shown that emergency departments can treat patients faster if these are assigned to a ‘track’ for treatment depending on how acute their condition is.

For example, the Central Hospital in Karlstad succeeded in introducing more effective working methods by have a physician quickly see the patients for assessment and either sent home or kept for further treatment (which could involve some waiting). At St. Göran’s Hospital in Stockholm, managers try to place the more senior doctors earlier in the care chain, as opposed to as most hospitals do with the first patient contact usually being with much less experienced doctors. The reasoning at St. Göran’s is that having a more experienced doctor meet patients earlier reduces the risk that a patient will have to wait too long for their condition, and that any patient will receive an incorrect diagnosis.

There is good reason for working to utilise health care resources more efficiently by changing procedures and routines to significantly reduce patient waiting times at emergency departments, as we see happening here in Sweden and internationally.

Read more:

Hospitalconnect.com (2009). ”Ongoing Transformation of the ED”, HPOE Case Study, 2009-07-10.

SBU – Statens beredning för medicinsk utvärdering (2009). ”Akuten blir snabbare med olika ‘spår’”. Triage Methods and Patient Flow Processes at Emergency Departments (http://www.sbu.se/en/Published/Yellow/Triage-Methods-and-Patient-Flow-Processes-at-Emergency-Departments-/)

Nima Sanandaj

19 January, 2013