There, time is relative, and more a matter of perspective than physics.
To a trauma team struggling to get an accident victim into treatment before golden hour expires, time rushes by at triple speed. To walk-in patients in the waiting room, trying to endure the pain of a sprain, the fever of the flu, or the nausea of food poisoning, five minutes can feel like forever.
Then, after their name is finally called and they are in a treatment room waiting for a doctor, what happens if more ambulances roll up from an accident with multiple injuries? They may find themselves waiting alone in a cold treatment room, wishing for a blanket, needing to use the bathroom, and wondering whether maybe they were forgotten. Should they go to the door and remind someone they are here?
Emergencies vary in acuity and don’t happen on a predictable schedule. With traditional emergency room models, time almost always plays a critical role in severe cases, and in less urgent cases, waiting out of proportion to the time actually needed for treatment is all too common.
Memories of long waits in the past can have an unfortunate effect when people are deciding whether to have chest pains checked out, or wait to see if it’s just indigestion. After all, last time, between triage, filling out forms, repeating symptoms to several people, talking to the doctor, getting labs, waiting for results, getting an injection and then waiting to make sure they didn’t react—they and their spouse lost most of a night’s sleep for something that was essentially nothing. Unfortunately, if it is something, delays can be deadly.
In planning the move from Trinity to Grandview Medical Center, a key priority of the Emergency Department was to rethink every aspect of design for better patient flow and the most efficient use of time and space.
“We had an opportunity to create the emergency department we had always wanted, and plenty of time to consider a variety of ideas,” Emergency Department Director Mike Gaither said. “When we looked at the bottlenecks in traditional emergency department design, it was clear that many of the problems came from trying to move all patients through the work flow of a single track, even though their needs could be very different.
“So we began by designing two different pods, each with its own staff and facilities. The pod for acute patients is near the ambulance entrance and helicopter access. The pod for non-acute patients is on the other side, with drive up access and valet parking during the busier times of day. There are multiple triage areas. If walk-in patients have something more serious going on, we move them across the hall for acute care.”
Emergency physician Jeff Jones, MD said the entire staff drew on their experience to contribute ideas for making the new facilities more efficient and user friendly.
“The emergency department is located on the same floor as radiology and the cath lab, so most of the imaging and labs are easily accessible,” Jones said. “We also have gurneys that are already set up for x-rays, so we don’t have to move patients to another stretcher. This is especially helpful with orthopedic injuries and other conditions where we want to avoid unnecessary movement.”
Gaither said, “Much of the equipment our physicians and staff use is portable, so we can bring the equipment to the patient rather than taking the patient to the equipment. X-rays and other imaging can be reviewed on a computer screen in the patient’s room. We have portable casting, portable suturing and other equipment that can be moved from room to room as needed. There are also specialty rooms for cardiovascular emergencies, orthopedics, obstetrics and other types of emergencies.”
Jones said one of the biggest efficiency challenges for most emergency departments is communication.
“In a true emergency, you can’t afford to waste time tracking people down, and even in a simple case, if you have to go and find everyone to tell them what the patient needs next, it can add a lot of delays to the process,” Jones said. “We have phone for everyone involved in a patient’s care. If we need to talk with each other or ask a question, we can either call or text. With less paging, there’s also less noise.”
The centerpiece of communicating with the care team is the Emergency Department’s electronic tracking board.
“We can all see what’s happening with a patient just by looking at the board. I can post an order for an x-ray or another procedure, and I can see when a patient is finished with labs.” Jones said.
Another eureka moment in moving patients from the waiting room to the treatment room faster came when the ER designers started looking at how much time patients spend in the same room just waiting for test results.
“That’s where the idea for our results-pending unit came into play,” Gaither said. “By moving patients to a comfortable, private place where they could wait for results, we could also free up a room to move the next patient in faster. Moving into a different room rather than continuing to look at the same four walls also helps patients feel that they are making progress.”
An accredited cardiac pain center and level 3 trauma center, Grandview is the official healthcare provider for Talladega Speedway, NASCAR, Barber Motor Sports and men’s soccer. The hospital is also geared up to handle high school athletic injuries. And helicopters bring in transfers from smaller hospitals to the south and east.
“Even before patients arrive, we can pull up electronic records or communicate with EMTs and begin the preadmission process, including designating a treatment room and staff, and alerting other resources we may need,” Gaither said. “When EMTs bring the patient in, they can look at the tracking board and see where to take the patient. Then they can go to our EMT lounge to work on their notes and reset for their next call.”
The ER department also offers workshops for EMTs and conducts four drills each year in cooperation with state and local emergency management agencies.
“We do a snow drill, a tornado drill, and a drill simulating mass casualties at a race track. The fourth drill involves hazmat,” Gaither said. “We have a separate entrance for hazmat emergencies, and a staging area between the helipad and decontamination. There’s a separate drainage system, hazmat suits and plenty of gear for handling a wide variety of hazardous materials emergencies.”
Grandview is set up to care for patients of all ages, including the pediatric sized equipment for treating small children. If a pediatric patient needs to be admitted, they have a transfer relationship with Children’s Hospital of Alabama.
“The improved design and the technology are great, but I’m most proud of our people,” Gaither said. “We had a terrific team at Trinity, and we knew that when we moved we’d need to double the staffing. We wanted the best, so instead of recruiting in the usual way, we did it by word of mouth. We asked our staff who the best people were that they knew. When we heard the same names, we knew who we wanted.”
So how well is this new approach to design and patient flow working? You can see for yourself online. The emergency department posts its average waiting time, updated every fifteen minutes. Often that waiting time is zero.
“We’re very pleased with the efficiency we’re seeing in both the acute and non-acute pods,” Jones said. “In fact, we could easily handle more routine urgent non-acute cases and still have very good times on getting patients out of the waiting room.”
Those excellent waiting times should continue as the department grows and patient load increases.
“When we were planning, we had the future in mind,” Jones said. “We designed the layout with plenty of room to expand.”
