Cutting ER Wait Times

SHARON H. FITZGERALD

Cutting ER Wait Times

Two Nashville Initiatives Attack the Problem from Different Perspectives

When patients sit in a hospital emergency waiting room, here’s what happens:

The patients aren’t being treated, and their condition may be deteriorating.

Emergency vehicles may be diverted.

The hospital isn’t making any money.

The patients and the providers are frustrated.

There are surely more unfortunate outcomes that could be added to the list, but you get the idea. Alan B. Storrow, MD, and Mary Bufwack certainly get the idea, and both of them are working — in very different ways — to help alleviate the problem. You could say one approach is high tech, and the other is high touch.

High Tech

An associate professor of emergency medicine at Vanderbilt University Medical Center, Storrow and several colleagues devised a study to determine whether laboratory testing in the emergency department, and perhaps even at the bedside, (as opposed to in a central lab) could decrease patient ED length-of-stay and increase patient throughput.

The study results, presented in May at the annual meeting of the Society for Academic Emergency Medicine, “were pretty compelling. I didn’t think they would be as good as they were,” Storrow said. “It just makes sense from a clinician and patient standpoint. Part of the problem has been proving that a difference can be made, and that it’s worth the extra cost.” He called that cost “not insignificant,” from three-to-six times more per test, depending on volume.

To examine the problem of ER sluggishness, Storrow had a head start. VUMC’s Department of Finance had hired an outside company to model ED processes through computer simulation to figure out ways to improve efficiency. Thus, real-time data already existed on day-to-day ED operations. “So that makes the model very robust,” he said.

The researchers then “dialed down” in increments the time it took to order, conduct and report diagnostic tests from Vanderbilt’s central lab. What they found is that, with point-of-care testing, lab turnaround time dropped from 120 to 10 minutes; average diversion hours daily decreased from 10.8 to 6.0; average daily throughput increased from 104 to 120 patients; and their length-of-stay decreased from 2.77 hours to 2.17 hours. Storrow said “ideal” lab time was determined to be about 20 minutes, and that less than 20 minutes didn’t make a significant difference (see chart).

“So I can say with some confidence that these measures can be improved,” he said. “My work has suggested very compellingly that you can increase efficiency to the point where it makes a great deal of sense, not only from a cost standpoint, but from a physician standpoint and a patient standpoint.”

Some hospitals already are sold on the idea, establishing either an ED lab or some bedside equipment for quick analysis. “The technology has advanced to the point where there are even devices that you can hold in your hand — get the blood, put it in a cartridge and put it in a machine literally right at the patient’s bedside — and get a result while the physician is in the room. These devices are good, and they are accurate enough for clinical decision-making,” Storrow said. As far as an ED-based lab, he suggested that it could be set up to run “the 10 most common tests that make up 90 percent of your diagnostic testing in the ED.”

Based on Storrow’s research, Vanderbilt has a committee examining establishment of an ED lab. What’s more, Storrow is fielding calls from interested hospitals nationwide and presented his results last month in Germany to the European Society for Emergency Medicine.

High Touch

It’s no secret that hospital emergency rooms have become primary-care providers for a growing number of patients, but thanks to a two-year, $1.3 million grant from the federal Centers for Medicare and Medicaid Services, Nashville-based United Neighborhood Health Services (UNHS) is working to shift those patients away from EDs and into one of its five neighborhood clinics.

A private, nonprofit, primary-care provider targeting the underserved and uninsured, UNHS takes care of about 21,000 low-income Nashville residents a year. About a third are TennCare patients, and the rest are uninsured, according to CEO Mary Bufwack.

Using the grant money, UNHS so far has hired six social workers, called patient advocates, who work in hospital EDs during peak times. With a small office and computer access to the appointment systems of United Neighborhood’s clinics, the advocates sit down with patients who really shouldn’t be in the ED at all and help them schedule a primary-care appointment either later that day or the next day. Two UNHS clinics are open until 10 p.m.

Bufwack said this “real-time diversion” is happening at Vanderbilt and Skyline Medical Center so far, and UNHS is in negotiations with other Nashville hospitals. “These patients get some face-to-face contact. They (CMS) wanted to see a more personal, individual approach to helping people find a medical home and to intervene in a more permanent way. A piece of paper with some phone numbers didn’t do that. … Now these patients get more than a piece of paper. They actually get an interview,” she said.

The program kicked off in August. “So far, interestingly, we’re getting about 70 percent compliance,” Bufwack said. “Isn’t that amazing?”

Another benefit is the opportunity to initiate preventive screening for patients who otherwise don’t seek wellness care and to identify underlying chronic problems that can be treated affordably in the clinic setting. The result, of course, is lower healthcare costs in the long run for traditionally problem populations.

The commitment by hospitals is small, basically the donation of office space and the training of ED personnel to recognize when patients should be funneled to the UNHS patient advocate. United Neighborhood dedicates an advocate for seven to eight hours a day at the hospital’s peak ED times. “We’ve tried to just really be flexible, because a program that doesn’t meet the needs of the hospitals isn’t going to be welcomed,” Bufwack said.