Emergency room overcrowding continues to be a costly struggle for many hospitals and healthcare organizations. Patients who are admitted to the hospital from a crowded ER typically spend more time in the hospital, cost more to treat, and are more likely to die in the hospital.
With the stakes so high, many hospitals and healthcare organizations have experimented with solutions to improve patient throughput and reduce ER overcrowding. Here are a few examples.
With the advent of quality improvement initiatives and value-based purchasing, complete and accurate clinical documentation is vital; however, good documentation takes time. Studies show that ER physicians spend nearly a third of their shift on clerical work, which limits the number of patients they can treat.
The scribe is an emerging medical profession whose job is to shadow physicians, take notes during each patient encounter, and enter the information into the appropriate electronic medical records. This saves physicians time, boosts productivity, and improves job satisfaction.
Scribes also allow physicians to have more natural conversations with their patients because they are not frantically trying to jot down every relevant detail with their face turned away from the patient.
A 2014 study found that using a scribe in the ER improved all throughput metrics, which included door-to-room time, room-to-doctor time, door-to-doctor time, doctor-to-discharge time, and length of stay for discharged/admitted patients
Combine Fast Track and Triage
In an effort to decrease ER wait times, The St. Louis Veteran’s Association Medical Center (VAMC) tweaked its ER triage protocol.
Originally, a pre-triage nurse would screen each patient. Patients who did not have an emergent condition were referred to resources outside the ER and others were directed to triage. The triage nurse would then interview and evaluate the patients to determine if they needed treatment in an ER bed or in the Fast Track Unit.
The new process eliminated the second triage step. A pre-triage nurse screens each patient, moving the moderate to high acuity patients directly to an ER bed and lower acuity patients to the new triage/Fast Track area. Physicians treat the higher acuity patients while the Nurse Practitioners (NP) and Physician Assistants (PA) care for patients with less serious conditions. Upon further evaluation, the PA or NP may also move the patient to an ER bed if he or she believes such care is required.
The experiment worked, and VAMC reduced the mean ER length of stay by 15%.
A study that examined nine Boston-area ERs found that length of stay and ambulance turnaround time in those departments actually dropped after the city implemented its ban on ER diversion.
ERs will typically divert patients to other ERs when they are experiencing high volume as a way to manage overcrowding; however, this study showed it doesn’t work.
The diversion ban reduced length of stay and ambulance turnaround time by 10.4 minutes and 2.2 minutes respectively. The improved throughput also led to a 3.6% increase in patient volume.
Study coauthor Laura G. Burke, MD, MPH, told HealthLeaders Media, “If you want to impact [ER] crowding, ambulance diversion isn’t the best way to go about it. Hospital-wide factors such as lack of bed availability or insufficient staffing cause boarding in the ED, which is a much greater contributor to crowding.”
The University of California San Diego Medical Center experimented with telemedicine in the ER, and found that patients who were treated with telemedicine had an average wait time that was about half the hospital’s overall average.
Patients with conditions that are appropriate for the ER telehealth program are moved to one of six bays, which house television screens with high resolution video equipment and high quality audio. The physician appears on the television screen and uses specialized equipment, such as an electronic stethoscope and a small camera to further examine the patient.
As part of the pilot program, all patients who were treated via telemedicine were also screened by an onsite physician to ensure nothing was missed. According to the facility’s Emergency Medicine Chair, there is no evidence that telemedicine encounters are more prone to misdiagnosis and miscommunication.