ER's May Now Take Reservations and Fast-track Patients

The number of patients heading to the emergency room (ER) is growing, but surprisingly the waiting times are not. According to the Centers for Disease Control and Prevention (CDC), from 1993 to 2003, ER visits rose 26 percent in this country. But the average waiting time of 46.5 minutes before seeing seen remained the same as it had been in 2000. They credit that stability with the innovations applied by ER departments.

For the University of Alabama Birmingham (UAB) Hospital, efficiency innovations meant pods. When they moved to their new facility in 2004, they divided their ER into a six-pod system, including one that serves as the waiting room. Other pods serve critical patients, infectious patients, and in the back toward the ambulance entrance, trauma patients. The pod designations can be flexible to suit need.

"The pod system was notably different for us, and we did see an increase in efficiency," says Janyce Sanford, MD, Chair of Emergency Medicine at UAB Hospital and UAB Highlands. But it's hard to delineate how much to credit the pod system versus the substantial increase in beds from 22 to 46.

What they did see was an immediate increase in volume of 20 percent. "If you build it, they will come," Sanford says. This year, the UAB emergency department will see about 63,000 patients. The UAB ER is one of only four state-designated Level I trauma centers in Alabama and the only adult hospital in Birmingham.

Unlike most ERs, though, UAB Hospital sees few low-acuity patients. "That population is so small here at three percent that we couldn't justify one entire pod for them," Sanford says. The UAB Hospital ER does have a three-bed area designated for low-acuity patients, but they've been working with emergency medical services to shunt lower-acuity patients to their UAB Highlands Hospital.

Cullman Regional Medical Center (CRMC) undertook a major overhaul a few years ago. As with most ERs, a common community complaint was the wait time for simple injuries lasting around two hours. "Patients thought it should be quicker, but they didn't know they had three ambulances and a heart attack patient before them," says Cheryl Bailey, RN, BSN, MBA, and Vice President of Patient Care Services.

So CRMC took their ER apart and looked at it with a fine-tooth comb. They implemented management models to improve their processes [see September issue], and invited everyone to look at every aspect anew.

As a result, they found five rooms in the back not being well utilized. "You can see a space every day and still not see it," says Bailey, which is what made the minute scrutiny of the transformation so effective. "When we found those rooms, that turned into our ExpressCare."

ExpressCare moves low-acuity patients through a different process and space in the ER, shortening their stay without impeding the care needed by more acute cases. "We had heard of it but had not implemented it, because we didn't think we had the space," Bailey says.

Cullman studied their flow statistics and found the busiest ER times lasted from 10 a.m. to 10 p.m. So their ExpressCare system runs those 12 hours every day. "Then it typically calms down. But it may still be open at midnight, if we're crazy back there," Bailey says.

"This has been wonderfully satisfying for our community," Bailey says. With ExpressCare, low-acuity patients are in and out within 75 minutes. The wait time average used to run two-and-a-half hours, a 50 percent improvement. "We post the emergency room and ExpressCare wait times on a board every day. It's always been less than 90 minutes," Bailey says.

The same emergency physicians group, Pegasus, that mans the Cullman ER also staffs the Princeton Baptist ER department. Princeton's ER began their own ExpressCare program in August. They've dedicated six of their 25 beds to the new treatment area.

"The key part is identifying the low-acuity patients," says Jeremy Rogers, MD, and Medical Director of the Princeton Emergency Department, who has seen ExpressCare in play at other ERs in the nation. "For triage, we use the Emergency Severity Index (ESI) scale to determine who goes to ExpressCare."

The five-level triage system not only takes into account the patient's condition, but the resources required for diagnosis and treatment, making it very useful for pinpointing patients best suited for fast tracking through an ExpressCare.

With only a handful of weeks under their belt, Princeton can't yet quote statistics, but Rogers says there's been significant improvement in the waiting time. "When the waiting room is really full, you're able to decompress rapidly." Princeton expects about 30 percent of their 42,000 ER patients to fall into the ExpressCare category this year.