Emergency Department (In)efficiency - Why patients wait 6 hours...and die in the waiting room.

I've worked at more than a few places...both EDs and urgent cares. I can finally say I now fully appreciate the difference between a 'physician efficient' ED and...one that's not.

One of my gripes about working in the ED as a doctor is...the place isn't set up to maximize physician efficiency. Sure, they expect you to see 2.5 patients an hour...but when it takes 20 minutes to log into the various computer programs, trouble shoot the printing process, and then find said printout to sign and place with the chart (if you can find the chart)...there's no way the "goal" of 2.5 patients can be reached.

Let's take last night...
...there were 4 docs there, only 2 computers available for our use. My kindergartner can tell you that 4 docs need 4 computers. As everything is computerized now, I can't even look up lab results, or discharge a patient without using the computer. So, I found myself standing...waiting...for a computer to open. While patients have been in the waiting room for 6 hours or more. Then, when 'productivity' scores are released, it seems we're just...slow. And to compensate for the utter inefficiency of the system...doctors are expected to 'just speed up'. Making an already stressful, high-liability, acute situation...even moreso. There are only so many corners you can cut. So, some of my colleagues will opt to stay hours past their shift, doing charts, and continuing to dispo patients...stuff that they should have done hours prior (which would be both better for the patients we've seen, and for the patients in the waiting room), but couldn't for fear of slowing down...and being the "slowest person in the group." So, the patients (all of them) endure less than optimal medical care.

Why do we let them punk us like that? 10 hours of work should be done in 10 hours. It should not be expected/required that you do 12 hours of work in 10 hours. If the system is so inefficient that only 1.75 patients/hr can be *properly* seen...that's how many we should see. And charting/paperwork shouldn't be saved until the end of the shift. Documentation as you go is more accurate, and provides better communication to consultants and other healthcare team members. Above all, it allows you to keep everyone straight, and demonstrates real-time decision making and outcomes. Not to mention it's a total pain in the ass trying to gather all the pieces of information needed to compose a good note...after the fact.

So, what have I noticed that distinguishes 'efficient' EDs from 'inefficient' ones?

1. Smaller is better. The new trend is to build these 'mega emergency departments.' Where everything is spread out...very pretty...but inefficient. If you have a large ED, you need to break it down into essentially 2 completely different departments. Where one doctor is in one area...period. Not theoretically, but actually. There are EDs where the idea is to have one doc in an area, with a couple/few nurses...and that's where they stay for the entire shift. But in actuality, the doctor's patients are placed all over the place...in various areas...depending on "which nurse is up next to receive a patient." Additionally, the beds fill up in a particular area, depending on the disposition of the patients, their acuity, etc. So, patients will then be placed...anywhere there's room. Seems logical on the surface. But, then you have a doc running around this big ass ED, trying to care for patients from one corner to the other. This is inefficient, and slows down the flow. This ultimately is not good for patients. If the ED were to be divided (physically divided) into 2 discrete entities, this would not happen. Kind of like how Starbucks will frequently put 2 (separate) stores right across the street (or around the corner) from each other. It just works better...not having a huge, inefficient, chaotic, place to conduct business - but rather 2 (or more) completely separate places of business.

2. Each physician needs his/her own work station. As demonstrated above, it is a bad idea to require the usage of computers with not enough work stations. Waiting in line for a computer...isn't conducive to ED flow. And, not just random computers should be available...but rather each doc their very own. That way, you can set up the computer...log in...and not have to worry about getting up for a second...and losing your spot. Additionally, I could argue that this is better for patient privacy.

3. The computer should stay logged on. I'll approximate that I spend 30 minutes a shift logging on to various programs...each of which shut down after a couple of minutes of "idle time". Another joint commissions bright idea, I'm sure. HIPAA, CMS...someone who doesn't understand the practical impact this has on ED flow and subsequent patient care. The computer should be in a place that patients don't have ready access to. Once I log on, I should stay logged on. Perhaps there should be a way to tell the computer how long I'm working, and to log me out at the end of my shift. But logging on every 2 minutes...is not the most efficient option.

4. Speaking of logging on...can I have 1 login name and 1 password? Currently I have like 4 different login names/passwords. So...I end up writing them all down in my pharmacopoeia. I also see people put little stickies on the side of the computer. It has to be 'safer' and 'more protective of patient data' for me to have 1 login/password in my head versus all my info in a book...or on a stickie pasted on the side of the computer!!

5. And, can we quit changing the passwords every 3-6 months. This is another reason you find passwords on scraps of paper, stickies on the computer, or written in frequently lost pocketbooks.

6. Decrease the scut. Can we hire a clerk, high-school student...anyone, that can load the printer with paper, keep the necessary documents stocked, and print out aftercare instructions and acquire the patient's signature? I do so much scut...it's no wonder patients wait for 6 hours. It takes hours of my day printing pieces of paper, signing them, and placing them with the chart (after finding the chart). When my lab results are available, put them with the chart and notify me. When my radiographs are done, do the same. If an extended period of time has passed, and the data remains incomplete, call the lab, call the xray tech...find out what's going on, and fix it.

7. Have ED techs set up procedures, irrigate wounds, gather equipment, etc. And when rooming a patient, place them in the appropriate space. ENT, eye, Gyn, etc.

8. Have the nurses take less breaks. Man, they are *always* on break. I must say, I'm very jealous. We get no breaks. I can't even urinate or take a sip of water during many of my shifts. They get like a 45 minute 'lunch' and 2, 15 minute breaks. I can only dream!!

9. I need necessary work items in my work area. Can we have needed documents, trash cans, printers...you know, the things we need to work, near our work stations - and not solely across the way in the nurses station? It is a poor use of my time to make multiple trips *per patient* to the island for supplies when those very items could be placed in a spot more convenient for me.

10. The location of my patients matter. Ultimately, the flow of the ED, how many patients are seen, and how quickly they are dispositioned depends on me. And if things are not set up for me...the ED doesn't work well. Ancillary staff and nursing are important...but so am I. That needs to be taken into consideration. It's easy to understand why the nurses need their patients together, so why would it be any different for the physicians?

11. Don't bring patients back from the waiting room until they are ready to be seen. Bringing a patient from the main lobby into a smaller waiting room is a stupid idea...and only serves to frustrate the patient. Just when they think they're going to be seen, it's more waiting. Kinda like being in line at Disneyland, going thru the maze...thinking you're finally at the front of the line...turning the corner only to see a brand new maze. This frustration on the part of the patient only serves to slow us down...and lowers customer patient satisfaction scores (for those in admin who seem to get a hard-on over such things). It doesn't help when patients are constantly coming out of their rooms (or this "inner waiting area") to bitch and complain about the wait. It just slows us down even more. The lobby is a perfectly fine place for them to wait.

12. One thing that worked well at one place I worked: have the clerk call the medicine consultant. We, physicians, requested a medicine consult by asking the clerk to obtain one. She wrote the patient's name, chief complaint, and a 1-2 line "reason", that we provided, on the book. When they returned the call, she gave the consultant that info, and they came down. If they had questions, or we had a more acute patient, of course we'd be more aggressive and communicate more directly. But for the routine 'chest pain r/o MI' on a patient that you know didn't have an MI, but you can't send home because 'what if he did?'...this process works well. And most of our admissions are more or less well-appearing, low risk, CYA, bullshit...so, why fake the funk? Why waste time calling medicine and hanging around until they return the call for these patients? It's not like they won't come see the patient. The process is streamlined, and it works very well.

13. Writing holding orders for admission works well.

14. Paperwork. There's absolutely too much paperwork. Documentation, is done for billing, and less so for patient health information communication...which is unfortunate. Much of what we write is irrelevant, but required for payment. Therefore some medically pertinent items are excluded...because there just isn't enough time to do everything. Decrease the number of sheets of paper, and the amount of random bullshit we need to include for payment, and things will move faster.

And finally an ED Wish
I wish I could go out to the waiting room and tell people "Look, tonight is busy...and if you're not very sick, the wait is in excess of 5 hours. We'll see you, but don't ask us 'how much longer?'" It seems appropriate to tell people the honest answer to that frequently asked question ("How much longer, I've been here for 3 hours already?")...but we don't. We say "ummm, weeelllll, it depends on how sick people are....I don't know exactly....yadda, yadda, yadda", when in fact we absolutely know that it won't be in the next 5 hours!! We did this a few times in residency...and the ED waiting room cleared out. Non-urgent people left, and the emergent people got better care. I also heard about UC Davis doing this rapid screening (meeting EMTALA) then sending people out *from triage* if they were non-emergent. The only thing is...the paperwork is a rate-limiting factor, even in a 'rapid' triage system. If that could be stream-lined....the ED would work so much better.

Getting feedback from those of us *actually working in the ED* is the best way to make things better!!


scalpel said...

Great post. My biggest pet peeve is the automatic logout.

Anonymous said...

Here in Indianapolis, Indiana we have a public hospital that is called Wishard. Most the staff and the patients call it: Wish your not there, Wish I dont have to go there, Wish they dont kill me, Wish I dont get worse-pital. I totally agree with your comment about telling the patients the actual waiting time. We are having a serious illegal Mexican problem where I work there and they seem to come in with tooth aches and in-grown toe nails several times a shift. I think that if someone came out and handed them a sheet telling them the clinic hours and locations for "business hours" and weekends as well as telling them that the wait will be 6-8 hours they will get the idea. The horrid thing is that most of the time it is either one 'toe nail type' injury and they bring half their family or they choose to bring a toddler. When our one of many translators came out and told this grandmother who brought her 2 year old grandaughter with her who was licking the seat, the legs of the seat, licking her fingers after using her salive to paint on the flor that there were viruss' and bacteria here and 100-fold since this is a public hospital ED. The lady totally freaked out. The translator told us later on that she said that she thought the hospital was sterile and the floors and seats were treated with special stuff to prevent germs! I am not a racist but the illegal latino population is really causing us a MAJOR problem in the ED and the budget for translators is higher than the budget for paramedics who can do almost all the functions of the RN's and do our External Jugular IV's and "hard sticks". ******************************** Our private hospitals have come up with a MUCH better idea that has totally solved their waiting problems. As each of them has needed to remodel and expand their ER's (just normal every 30 year remodels) they have added more non-urgent rooms and put televisions in the rooms. I found this out when I started picking up PRN shifts at other ED's. Each had a "patient care assistant" who probably makes like $9.00/hr. His or her job is to bring the inexpensive juice, jello, or sherbert cups and gram crackers along with an extra blanket or whatnot. WE DO NOT HEAR ONE PEEP OUT OF THESE PATIENTS! IT IS AMAZING! That way we can treat patients in order of acuity and clear out the waiting room at the same time! The OTHER ED's (privates) have smaller no-frills rooms for the drunks/drug related problems that are closer to where security is. My friend who is a medical malpractice (med-mal) attorney told me that doctors who are friendly, polite and have nice bed side manner dont usually get sued (unless something MAJOR happens) because the people remember "that nice doctor". I dont know why county has not picked up on this. It is not like the private hospitals let people stay all day and watch TV it is just used for times when we have 10 shock patients and 3 docs. PLEASE PRAY THAT ONE OF THE HOSPITALS WILL HIRE ME AS I HAVE PUT IN APPLICATIONS FOR A NRUSING POSITION AT ALL OF THEM!!! It is totally amazing that the private hospitals still see PLENTY of medicaid/homeless/ETOH/ED/and etc. in their ED's and they have figured out many ways to combat the "waiting problem" such as above. Nobody dies in THEIR ED's because everyone in the acute rooms gets put on an automatic telemtry system. The cost analysis showed it was cheaper than ONE lawsuit. I cant wait to leave WIAHARD HOSPITAL INDIANAPOLIS, IN (home of the worst ER residency program and IU's FM/IM residency FACTORY)!

Couz said...

Hallelujah, brother.

RoseAG said...

Why not change all your passwords to the same thing?

I'll be every hospital administrator sitting in some office has got a PC on their desk!

Catron said...

Most of the things you're unhappy about are symptoms. The actual disease is overcrowding, and that can't be cured by less cumbersome passwords, etc.

The disease can only be cured by removing the perverse incentives that drive so many non-emergency patients to the ER.

As long as a trip to the ER costs the patients little or no up-front, out-of-pocket money they'll keep descending on the ER like so many Visigoths at the gates of Rome.

docbraypa said...

With respect to the password issue - I have at least six different accounts - practice, hospital, PACS, LAN . . .

I have a system - I always use a basic eight digit password (a mix of numbers and alpha characters) and then add a last digit number to keep a serial password.

Example - ####XXXX1 (First iteration)

Then when it comes time to make a required change just change the last digit - ####XXXX2

I then get the IT folks to reset the other passwords to the new password. After a couple times of this I have been told the steps to reset the passwords myself.

The system seems to work for me . . . now if I could get all the user names the same . . . now thats a much more challenging struggle.

Bodymender said...

The one concern I have about the constant "logon" and an unsupervised terminal is the lack of control over the scripting function. Huge potential for abuse by crafty parties.

Most would label this an internal control risk.

While this has directly happened to me - one provider hopped on to my terminal and forgot to logon with his ID. He sent off a script on a Pt. being D/C'd - who subsequently was transferred back to her nursing home. Several hours later I take a call from the charge nurse of the facility asking for confirmation of the med - quick reference to the EMR showed I had never seen the Pt. After a bit of back tracking I was able to discover how the script was sent out under my name.

From now on - I log off - before moving on.

EDRN said...

Where is this hospital? I'm an ED RN and we never get breaks, we are shocked when we get a 30 minute lunch. Now the ED Techs have it made, they answer to no one, are not monitored and get breaks and lunches whenever they'd like.

EDRN said...

Where is this hospital? I'm an ED RN and we never get breaks, we are shocked when we get a 30 minute lunch. Now the ED Techs have it made, they answer to no one, are not monitored and get breaks and lunches whenever they'd like.

Anonymous said...

Holy casserole! Nurses get a 45 min. lunch and 2 15 min breaks? Where is this wonder of hospitals that you work so I can sign up? I'm an ER nurse and I'm lucky to get a 30 min. lunch with NO breaks. Often the lunch is interrupted many times by a doc who needs something, or a pts family, or the pt. themselves. Not that I'm complaining... I love being an ER nurse, and work well with all the docs on duty, even residents (who often rely on nurses to confirm certain things...). Another thing. You can always find a nurse to do something for you, even if it's not that nurse's patient, but you can never get another doc to do anything for a pt that isn't theirs. Weird, don't you think?

Yeah, I took offense at your "nurses always on break" comment, mainly because I'm jealous. I find your blog very interesting however. Thank you.

Castillonis said...

Wouldn't it be better to realize most of these changes so that you have time to take care of yourself instead of being jealous of nurses. Your kidneys would probably love it :) There needs to be more balance between administration/management and medical input. We also need to focus on providing some type of primary care and focusing on prevention/education instead of choosing which poor recieve care. It is much less expensive than the mess we have now. Look at the archimedes project.

Nurse K said...

The location of my patients matter.

At some point, they tried to divide up the physician's rooms (they're already divided by 6 critical care to one doc and 12 non-critical care [plus hallways] to two docs) on the side of the ER with the two doctors, and it was just gridlock. The slow doctors couldn't do their fair share and the fast doctors were sitting around playing solitaire in the middle of the chaos. I should say that it seems our ED is especially well-doctored according to others. 17+ beds and 3 doctors from 10a-1:30a.

Sorry, but we keep our rooms full and don't really care about being the hostess at a restaurant and "seating" the doctors in even fashion. It would take a really long time if we had to ask permission to seat your table, I mean room, prior to rooming a patient.

You have time, grab the chart. Don't have time? Wait until you have time or else we'll tell you which patients are REALLY sick and need to be seen NOW.

Probably your ER is just under-physicianed. Ours have PLENTY of time for solitaire and eBay.

MY OWN WOMAN... said...

I'm an ER nurse and I'm almost sure that I will be incontinent when I get older because I don't have time to take a break or pee on my shift; and if I do, it's because the yellow golden fluid is about to flow down my leg and it's do or die. Most of my ER nurse cohorts are pretty much the same way.

Otherwise.......great post doc....you have some very valid griefs and we share them with you.

Anonymous said...

Your computer problems are based on notions of computer security that weren't so much researched as pulled out of someone's ass one day. Whoever made them up must have been a good talker, because he got everyone convinced.

It bullshit, of course, and you see what happens when you are forced to come up with 4 or 5 different passwords and change them every so often. There is no actual risk associated with not ever changing your password, as long as it was a strong password to begin with. One strong password is orders of magnitude more secure than a series of weak ones. And if there's going to be a series of them, they're going to be weak one way or another because we all have better things to keep in our heads than this month's password for computer system X. So you end up either picking one that's easy to remember -- which is almost certainly going to be weak -- or writing it down somewhere, which is the most non-secure thing you could possibly do. The alternative is not being able to get your work done, which is even less acceptable.

One password. Make it a strong one, with mixed cases, numbers, and punctuation, and at least 8 characters long; the longer the better. This can be hard to remember, but it's doable if you don't have to memorize any others. Don't change it so that users don't have to resort to mnemonic devices that can reveal themselves to the determined cracker. This is the most secure arrangement as confirmed by actual research, not just from some lamebrain chair-warmer.

The other reason for a login is, as another comment pointed out, authentication. When you write orders, they have to look like they're coming from you. It would be nice if there was a workstation that was yours and yours alone, but the advantage of being able to work from any station in a pinch is too great to discard. The obvious solution is to let you all log in with a badge swipe. This is a hospital. You all have badges, and I assume the all have magnetic stripes with your information on them. (If they don't, it's not costly to switch to ones that do.) Use the badge swipe for both login and authentication, and you have a system that's just as secure as your badges are (I assume you don't let just anyone walk around with your badge), maybe throwing in a PIN for good measure. You could log in as fast as opening the door to a restricted area.

Matt said...

As someone who works in the public safety data field (cops, fire response, EMT, etc), I understand the conundrum.

The answer is biometrics....use a fingerprint scanner to provide access at either the login level or application level. That, plus a password, creates a legally acceptable authentication. As someone who designs these systems, I can state that the initial rampup is hard, and people get cranky about having their fingerprints sampled in as authentication material, but net-net they come to appreciate it both from a security and a CYA perspective.

Hope something works for you...

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