Patients, sometimes seriously ill or injured, are waiting for long periods in emergency departments (EDs). Emergency department staff and doctors don’t want this to happen — no one does. So why is it such a prevalent problem? In April 2008, the American College of Emergency Physicians (ACEP) published a report discussing the issue: “Emergency Department Crowding: High Impact Solutions.” Experts from Children’s Hospital, Shelby Baptist Medical Center and Trinity Medical Center agree that processes are being put in place, and EDs are doing what they can to limit long wait times and overcrowding. But the problem is not simply an ED problem. It’s a hospital-wide problem, which must have a whole-hospital solution. Overcrowding “is a problem with the capacity to take care of the patients who have urgent problems,” said Dr. Peter Glaeser, Children’s Hospital’s division director of emergency medicine. The cause of overcrowding may seem obvious: Too many people go to the ED for primary care. However, according to the ACEP report, the primary reason for crowding is the boarding of patients in the ED. “Between 1992 and 2002, there was almost a 25 percent increase in the number of ED visits nationwide,” said Dr. Everitt Simmons, medical director for Shelby Baptist’s ED, “but during the same ten years, nationwide the number of hospitals and active EDs decreased by about 15 percent. You’ve got fewer inpatient beds, fewer ED beds and a vast increase in volume. So, we’re funneling a much larger number of patients through a smaller area, and we have fewer beds to put them in. It is multi-factorial, but it’s a hospital-wide problem, which is why we address it as such.” Crowding creates a number of problems ranging from inconvenience to potential danger for patients. “It increases the length of stay in the emergency department, it increases the number of people who walk out and get tired of waiting, and it increases medical errors that occur in the emergency department,” said Dr. Jeremy Rogers, Trinity Medical Center’s assistant chairman and assistant medical director of the emergency department. “One of the biggest problems in our area has been ambulance diversion. There have also been several other studies that show that when patients are diverted, their outcomes tend to be worse.” So, what steps have Birmingham-area EDs taken to minimize or eliminate this problem? In April 2008, Shelby Baptist Medical Center implemented a program called Kaizen, which means “good change,” to improve its ED processes. They began by reviewing “the process of patient throughput in the ED. By looking at the patient process, we examined waste that could be eliminated from the current process,” said Mollye Melton, RN, BSN, charge nurse for intermediate care for Shelby Baptist. “So we did a Kaizen to look at the average length of stay and to decrease that average length of stay. We reviewed all the processes to determine if there was any waste.” This Kaizen process allowed Shelby’s ED staff to implement changes as well as strive for continuous improvement, eliminate waste and minimize patient wait times. Children’s ED also constantly reviews its processes to find areas that can be improved and centralizes the patient so that they don’t follow the ED assembly line. ED staff members come to the patient instead of having the patient come to them. According to Glaeser, the staff also has “a large number of patient care guidelines, which are a set of orders that the nurses can implement with common presentations, allowing care to be provided without the physician seeing the patient yet. So, it’s allowed us to provide care that is standardized. A lot of our presentations are pretty standard. We know what they are going to need. Everybody knows what they’re going to need, so let’s just make it happen. That’s made, I think, a big difference.” The ED at Children’s also implemented electronic medical records for documentation and order entry. “We’ve centralized our process,” Glaeser said. “I can be anywhere in the department and put in orders for whatever needs to be done, whether it’s labs to be drawn or X-rays to be done.” Children’s will soon begin using i-STAT. “If we don’t get labs back in a reasonable turnaround time, then it’s going to make everybody wait longer,” said Glaeser. “We’re starting to do more point of care testing, and we’re about to implement something called the i-STAT, which allows point of care testing for some of the more common tests that currently take an hour to sometimes two hours for the lab to turn around; we can get it within seconds at the bedside.” Children’s, Shelby Baptist and Trinity have also implemented bedside registration to help minimize patient time in the ED. At Trinity and Children’s, if beds are available, patients are not sent through triage. According to Dr. Rogers of Trinity, triage “can become a bottleneck. Instead of facilitating the flow of patients into the emergency department, it becomes a bottleneck in the process. If you have open beds, then emergency departments need to be bringing those patients back. This is also a much safer practice. It’s safer to have patients waiting inside the emergency department as opposed to in the waiting room.” Since overcrowding is primarily caused by boarding patients in the ED, some hospital-wide solutions and support are needed to help lessen the problem. All three hospitals have taken steps to facilitate moving inpatients who are waiting for beds out of the ER. Shelby Baptist followed the same Kaizen review process to examine their admitting procedures. The hospital now has a floating admit unit for inpatients admitted from physician’s offices. According to Melton, when patients come from a physician’s office, they already have a bed waiting. They are walked to their room, and an admit nurse comes to them to admit them. “This decreases the wait time for the patient as well as decreasing the patient throughput in the ED, because patients who are admitted from a doctor’s office go straight to their rooms,” Melton said. Soon, Children’s Hospital will break ground on a new hospital. “It’s a major event for Alabama, in general, and Children’s Hospital in particular,” Glaeser said. “Our space will actually double in the ED. We’ll have 52 rooms. We’ll also be implementing a rapid admission next to the ED.” Instead of waiting in the ED or in the hallways in the hospital, patients will be sent to rapid admission. Trinity Medical Center now has an express admission unit for patients who are being admitted to the hospital when there are no ready beds. “Instead of waiting in the emergency department for a bed, they go to our express admission unit,” Rogers said. The Trinity administration has been supportive, according to Rogers, which is vital when addressing any multi-departmental issue. He also stated that hospital culture must change to fully solve the problem of ED crowding. “We understand that it’s a hospital-wide flow problem in getting patients from the entrance of the emergency department, admitted to a bed, and discharged in a timely fashion. A lot of variables go into that equation. Part of that requires a change in the hospital culture. Many hospitals still operate under a Monday-through-Friday, eight-to-five mentality. The majority of the services hospitals offer are available just during the week. The system needs to change to develop a 24-hour, seven-days-a-week mentality. That’s a difficult change, one that will require changing old habits. But certainly, services need to be available any time, because patients are coming to the emergency department at all times.” August 2008