ERs Move to Speed Care; Not Everyone Needs a Bed

AUGUST 2, 2011

By LAURA LANDRO

Hospitals are tackling a dangerous and costly side effect of emergency-room overcrowding and long wait times: the growing number of patients who get fed up and leave without treatment. To speed patients through the system, emergency rooms are adopting so-called o lean-management principles pioneered by such companies as Toyota Motor Corp. o to increase efficiency, o cut costs and o provide better service.

That means streamlining the traditional methods of triage and reserving beds for only the sickest patients, abandoning the longstanding rule that every patient gets a bed. It also means staffing the ER with less-costly providers such as nurse practitioners and physician's assistants, so more expensive ER doctors can focus on care and not on paperwork, test ordering and discharge plans.

To let patients know where wait times are shortest, health systems with multiple locations are o o o o posting ER waiting times online, in their waiting rooms and even on highway billboards. Hospitals are trying personal touches, too, such as calling patients to coax them back if they bolt.

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Waiting times that can run into several hours have become a fact of life in the U.S. The number of emergency departments has dropped by nearly a third over the last two decades, while the number of patients seeking care has risen almost 40% over the same time span. And the number of primary-care doctors is declining, even as more uninsured patients show up at ERs that are required by law to provide care.

The national average of those who leave without being seencalled LWBSwas about 2.7% in 200708, according to the most recent government data available. This is up from 1.7% between 1998 and 2006, according to an analysis by Johns Hopkins University researchers. In some areas, as much as a fifth of patients who show up for care end up leaving before they see a doctor. Many of these may go elsewhere for care or end up feeling better, but studies show that as many as half who left without treatment were judged to need immediate medical attention. One study found that 11% of patients required hospitalization within the next week, including some who underwent emergency surgery. "People who walk out without being seen are a measure of how we are basically failing as a health system in our ability to deliver important care in emergency departments," says Renee Hsia, assistant professor of emergency medicine at the University of California San Francisco. A recent study she led that was published in the Annals of Emergency Medicine shows the left-withoutbeing-seen rate in California ranged as high as 20.3%. Visitors to hospitals serving a high proportion of low-income and poorly insured patients were far more likely to leave without being seen. Patients who leave are a drag on hospitals' bottom lines. Revenue of about $450,000 is lost if even 1% of patients walk out of an emergency department with an annual volume of 50,000 patients, says Joseph Guarisco, chairman of the department of emergency medicine at New Orleans-based Ochsner Health Systems, which operates seven hospitals.

Dr. Guarisco saw the need for a more efficient way move patients through the ER after Hurricane Katrina, when the flagship Ochsner Medical Center's volume nearly doubled and its left-without-beingseen rate soared to 15%, from a historic rate of about 5%. His team designed a protocol called qTrack to rely more on providers like physician's assistants for lessill patients. Unlike traditional triage, which might take 10 minutes, qTrack has nurses giving a "quick look" evaluation to get basic information in three to five minutes. Less-ill patients aren't given a bed, but are offered a recliner or chair in a Continuing Care area, or are sent back to the waiting room to await test results or procedures. Dr. Guarisco says the changes have effectively doubled capacity in the unit and cut costs per patient visit in half. Average waiting times to see a provider have been slashed to about 33 minutes from hours previously, and the left-without-being-seen rate is below 1%. Ochsner Medical Center also posts ER waiting times at its other facilities near the registration desk. It will preregister patients who don't have a serious condition at another emergency department "so they can get in line before they leave the one they are in," says Dr. Guarisco. R. Devlin Roussel, who runs a charter fishing company, came to the Ochsner ER last Sunday with a painful infection under a toenail that had been nearly ripped off when a 120-pound tuna fell on his foot. After experiencing a long ER wait for a previous injury, he was surprised to find the waiting room empty. Within a few minutes he was registered and on an examination table. Mr. Roussel, 40, says he noticed a dozen other patients in various exam areas getting evaluated and treated, and saw another six or seven people come in and get processed quickly. "I was borderline shocked at how efficiently it was running," he says. A similar program, Door to Doc, which includes a model hospitals can use to match staffing levels to peak-demand periods, was developed by Banner Health, a 21-hospital system based in Phoenix, Ariz., with 680,657 ER visits last year. Kevin Roche, program director of process engineering, says that in some months before the program started up to 20% of patients left without being seen and the average time to see a doctor was more than four hours in some hospitals. At Banner Good Samaritan Medical Center, the Door to Doc program cut the rate of patients who left before being seen to 0.5% last winter from 8% in 2007, although the volume of patients in the department rose 4%. The nonprofit Health Research and Educational Trust, with funding from the federal Agency for Healthcare Research and Quality, is now sponsoring programs around the country for hospitals to learn about methods such as Door to Doc and qTrack. Sandra Schneider, president of the American College of Emergency Physicians, says doctors are receptive to efficiency programs, but warns they are just a "Band-Aid" on larger problems, such as the number of patients who are admitted to the hospital but left in beds in the ER because there are no inpatient rooms available. And being treated in waiting rooms and hallways, she says, can be "degrading and difficult" for patients.

Still, Holy Redeemer Health System's hospital near Philadelphia cut its rate of left-without-being-seen patients to 0.5% from 2.5% in 2007, says Henry Unger, chairman of emergency medicine. In addition to new fast-track protocols, the hospital also started using a staff "greeter" to circulate in the waiting room, check on patient and family concerns and notify a manager of any patient who leaves without being seen so they can follow up get them back in if need be. "We don't want them to walk out the door for their own health, but it's also not a good business model," says Dr. Unger.