Patient Congestion in the Emergency Room
How the patient is a solution to the problem
Dr Ashraf Amin Ahmed – Psychiatrist and Chief Medical OfficerDr Jonathan Bankoff – Emergency Medicine Physician and Medical Director
Dr John Baron – Nephrologist and Associate Chief Medical Officer Nurse Melissa Walter – Maternity Nurse and Chief Operations Officer
ED’s are stretched thin
Barish, Robert A et al. Emergency Room Crowding: A Marker of Hospital Health. Trans Am Clin Climatol Assoc 2012; 123: 304–311.
More visits in less EDs
Barish, Robert A et al. Emergency Room Crowding: A Marker of Hospital Health. Trans Am Clin Climatol Assoc 2012; 123: 304–311.
Disproportionate use of ER services for acute care
Barish, Robert A et al. Emergency Room Crowding: A Marker of Hospital Health. Trans Am Clin Climatol Assoc 2012; 123: 304–311.
Reduce ED congestion through patient involvement in service gap
closure
• Listening gap• Planning Gap• Service Delivery Gap• Communications Gap
Listen to those with answers• Patient discussion groups
• Hear from the patient about what troubles them• Online patient discussion blog
• Monitor and facilitate • Patient advisory counsel
• Vet policy and procedural change• Leadership bedside patient rounds
• Keep the ear close to the ground• Leadership – Staff Bulls and Bears
• Determine problems and brainstorm solutions• Focused patient feedback
• Brief questionnaire at point of service
Graphic from SBG pg 45.
Listen to those with answers• Train staff to listen
• Intentional listening at each moment of truth• Develop facile software program to log, organize and review
• Train staff in service recovery• Emphasize and reinforce RATER
• Responsive, Assurance, Tangibles, Empathy, Reliability
• Ensure staff members empowered with recovery options
• Develop “listening” subcommittee• Recurring meeting with formal agenda that reviews • Report to superior committee regularly
Graphic from SBG pg 45.
Listen to those with answersAnd Above all…
Stress the importance of active listening and demonstrating empathy and compassion with each encounter.
In many cases, an ear is all it takes to diffuse a situation. Always offer sincere thanks for a customer’s time to speak with them regarding their experience.
Graphic from SBG pg 45.
Design the ED for success• Much of health care gap management centers on
managing patient expectations and involving the patient in their care
• How well we meet patient expectations determines patient satisfaction
• Involving the patient in their health care and designing our care delivery around these expectations leads to improved quality outcomes• Closing Gap 2 helps close other gaps and improves the experience
Graphic from ZBG pg. 45.
Design the ED for success
Graphic from ZBG pg. 45.
• In the ED, much of our success is determined by well-thought out design
• One of the greatest challenges in EDs today is demand and capacity.– We often run out of room to see
patients due to long lengths of stay, boarding, and inappropriate use of the ED for non-emergent presentations
– To succeed, we need to better match supply to meet increasing demand and help educate our patients to better use available resources
– We must design the ED for maximum efficiency and then ensure that our patients use it properly
• We must actively involve patients in the design process.
Design the ED for success
Graphic from ZBG pg. 45.
• Methods / Designs for improving ED efficiency– Parallel processing, not serial: bring
resources to the patient, rather than making them go through a step-by-step process
– Bedside registration– Use of an Express Care area for low
acuity patients– Placing an ED Provider in Triage to
expedite workups / shorten LOS– Implementation of RN protocol
orders to expedite workups / shorten LOS
– Triage Kiosks in the ED WR– Online wait time clocks and ED
appointments to smooth patient flow– Streamlined IT services / EMR for
ease of use
Design the ED for success
Graphic from ZBG pg. 45.
• Methods / Designs for improving ED patient efficiency– Ensure proper use of the ED by patients by
keeping them informed of options and soliciting their feedback to improve processes
– Keep non-emergent / urgent patients moving vertically out of the ED
– Increase utilization of Urgent Care Centers and Primary Doctor’s offices
– Increase use of PAs and APRNs whenever possible
– Improve access / availability of UCC and PCP offices with extended hours (nights / weekends) to limit unnecessary use of the ED
– Educate our patients and community with the help of patient navigators, nurse educators, and multi-media
– Empower patients to make informed decisions
Run the ED for success
Graphic from ZBG pg. 45.
• Get the right people on the bus!• Generally, skill can be taught. Thus, hire for
service disposition – do they possess a “RATER” mindset?
• Hire hard, train easy• Train the right people
• Develop and execute best practice service delivery methods
• Ensure ongoing competency training and focused “touch-up training” as needed
• Retain the right people• Spend 80 percent of your time on your dream
team, and 20 percent on those who need to get on another bus.
• Develop a recognition program for strong performers.
• Develop an ongoing mentoring/coaching curriculum – the front line staff is leadership’s patient!
• Empower your dream team – don’t hold them back with red tape.
Run the ED for success
Graphic from ZBG pg. 45.
Manage supply and demandTrack hourly, daily, weekly, and monthly ED censusReview trends over the past year
Increase supplyHire locums/traveling nurse during peaksUtilize a hospital “float RN” system to respond to unexpected demandPay overtime for staff to work on off days
Decrease demandEnsure patient education in triageEnsure strong triage system in waiting room to
divert to PCM/Urgent careEnsure PCM clinic “on call” to handle during and
after hours non emergent medical careEnsure patients have real time feedback on wait time
based on chief complaint
Develop and execute Utilization Review CommitteeReview supply/demand/resource utilization appropriateness
Run the ED for success
Graphic from ZBG pg. 45.
Ensure the patient fulfills his role!-Encourage them to seek care at the
appropriate location-If at the ED waiting room and triages as non
emergent, help them obtain same day PCM appointment/urgent care
-Post patient comprehension-level data and discuss as required reduction of care quality in crowded EDs.
-Develop and execute a “coping” program for those who recurrently utilize ED services inappropriately(contracts, divert options)
Run the ED for success
Graphic from ZBG pg. 45.
Avoid problems with service intermediaries(Urgent Care, PCM’s)
Spend time with key stakeholders to ensure patient are able to
receive care at the appropriate triage level(ED, UCC, PCM)
Develop an Acute Care Utilization Review CommitteeStaffed by key ED, UCC, PCM staffAgenda focused on right provider right location
right time
Communicate for success
Graphic from ZBG pg. 45.
Integrate ED congestion solutions Remove silos between departments and insteadmaintain an intricate neuronal network of collaborationbetween ED staff, PCMs, Urgent Care clinics, and patients. The more we communicate the better we are!
We must all speak the same language so our messageto each other is intelligible and consistent. This isachievable through Gap 1, 2, and 3 action plans.
Manage Customer ExpectationsEnsure patient education of most appropriate useof health care resources
Demonstrate, though data and story telling, the harmassociated with ED crowding as addressed in gap 3.
Communicate for success
Graphic from ZBG pg. 45.
Communication “static” is still the number one causeof medical errors!
Repeat, restate, reiterate
Using Gap analyses with the patient as the focal point, let’s
“resect” chaos
Barish, Robert A et al. Emergency Room Crowding: A Marker of Hospital Health. Trans Am Clin Climatol Assoc 2012; 123: 304–311.
Using Gap analyses with the patient as the focal point, let’s “resect” chaos
Barish, Robert A et al. Emergency Room Crowding: A Marker of Hospital Health. Trans Am Clin Climatol Assoc 2012; 123: 304–311.
Using Gap analyses with the patient as the focal point, let’s “resect” chaos
Barish, Robert A et al. Emergency Room Crowding: A Marker of Hospital Health. Trans Am Clin Climatol Assoc 2012; 123: 304–311.
Let’s roll!
