Hospitals try new ways to curb emergency room crowding

Kaiser Health NewsJanuary 18, 2011 

WASHINGTON — When Katherine "Kitty" Foley tripped over a trailer hitch at last year's JazzFest in New Orleans and broke her wrist, she put up with the pain until the Average White Band finished its set. As a nurse, she knew she needed prompt care, but she dreaded a long, unpleasant wait in a crowded hospital emergency room.

When she did get to Ochsner Medical Center, she was stunned. The whole visit took less than an hour, including X-rays, pain medication, a soft cast and discharge instructions to tide her over until she got home to Cary, Ill.

"I was absolutely amazed," said Foley, who said she's about 60 years old.

Ochsner's is one of a growing number of emergency departments that are trying new approaches to ease crowding. The efforts have added urgency as some experts predict that the problem could worsen in coming years. They worry that as millions of people gain insurance coverage in 2014 under the new federal health care law, they may have trouble finding primary care doctors and will turn to hospital emergency departments instead.

For patients and hospitals, crowding involves more than inconvenience. Some patients get so tired of waiting that they leave without being seen. That's bad medicine, because they can end up sicker.

And it's bad business, because the hospital is left with lost revenue and unsatisfied customers.

"It's not only the person with a minor illness . . . who leaves," said Mark McClelland, a George Washington University health policy expert who's working with the Robert Wood Johnson Foundation's Urgent Matters emergency care project. "Someone who is very, very sick, who is at risk for significant problems, can be leaving. They came to you for help, and you failed your mission if they leave."

Hospital efforts to address the problem have ranged from high-tech options such as smart phone programs that let patients compare waiting times at local hospitals to something as mundane as staggering nursing shifts to match patient traffic better. "Fast tracks," or clinics for patients with simple complaints, are also common.

Some hospitals, such as Ochsner, are looking at more fundamental routines, shaking up and re-engineering their procedures.

Ochsner, for instance, created an emergency department protocol called "qTrack." The sickest patients still go immediately to the emergency department's traditional beds, but patients such as Foley go to separate treatment areas with comfortable recliners or to procedure rooms for stitches or casts. They await test results and discharge instructions in a post-treatment waiting room.

Treatment there can move faster and cost less. Foley never had to change into a hospital gown and get in an expensive bed with high-tech monitors. She just had to show the doctor her arm.

"Beds are the most squandered and overutilized resource in emergency departments," said Dr. Joseph Guarisco, the chairman of the department of emergency medicine at Ochsner.

The Banner hospital system, based in Phoenix, uses a similar approach, and the federal Agency for Healthcare Research and Quality highlighted it as an instructive case study for other hospitals.

Among the changes some other hospitals have tried:

_ The emergency department at Stony Brook University Medical Center in Long Island, N.Y., grew tired of having the hallways lined with patients on gurneys who needed to be admitted to the regular medical or surgical floors. It now has procedures to send some patients upstairs, even if it means they lie on gurneys in the hallways there, near the nursing stations.

That's helped the rest of the hospital become more attuned to the needs of the emergency department — and much faster at finding the needed beds, according to Dr. Peter Viccellio, the clinical director of emergency medicine.

"It's like a fire alarm that goes on at the institutional level. Everyone knows there's a problem in the emergency department; we're at capacity," he said.

_ Doctors at Providence Hospital in Washington used community health workers to identify emergency patients who, with a little guidance, could get their needs met in community settings such as primary care, HIV/AIDS or mental health clinics.

"They did a fantastic job of decreasing the return revisits," said Dr. Kim Bullock, the hospital's assistant director for the emergency department.

But the project ended when the yearlong grant ran out. Under traditional fee-for-service payment plans, Providence has no way of getting reimbursed for the work. The hospital is looking for another grant — or waiting to see whether the payment changes expected under the new health care law make programs such as this more viable in the next few years.

_ Emergency physicians at Good Samaritan Hospital in West Islip, N.Y., on the South Shore of Long Island, take over one of the hospital's walk-in surgery units after it empties out around 4 p.m. — just in time, because the emergency room generally starts getting crowded by midafternoon.

In addition to offering space, the program focuses on patients who score in the middle of the five-point triage scale, whose risks aren't clear-cut and who are often at risk for leaving without being seen. For example, does that patient have severe stomach flu, or is it an ectopic pregnancy or a bowel obstruction? An intense migraine or a brain bleed?

It's not clear that initiatives such as these can keep up with the growing number of patients in emergency departments, especially as some hospitals close and demand continues to grow from the ranks of the newly insured and an aging population.

In addition, there's no one easy answer; sometimes projects that are hugely successful in one hospital flop somewhere else.

And even as emergency departments work on new initiatives, some experts argue that attention should focus instead on the hospital as a whole. Dr. Art Kellermann, a Rand Corp. scholar and an emergency care physician, said such "work-arounds" let hospitals off the hook.

"The reality," he said, "is the rest of the hospital doesn't want to deal with the fact that the overcrowded ER is a sure absolute sign of a poorly managed hospital."

Not all experts share that view.

"It all depends on where you create bottlenecks," on the inpatient side or in the emergency department itself, said Dr. Joseph "Jody" Crane, an emergency physician at Mary Washington Hospital in Fredericksburg, Va., and a faculty member of the Institute for Healthcare Improvement. "It doesn't make sense to point fingers," he said.

Foley came away a believer.

"I thought it would be five or six hours; two hours to get in, another few to get out," she said. Instead, "I iced and elevated my arm like they told me to — but I stayed for the rest of the JazzFest."

(Kaiser Health News is an editorially independent news service of the Kaiser Family Foundation, a nonpartisan health care policy organization that isn't affiliated with Kaiser Permanente.)

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