The emergency department at Miami Children's Hospital had an emergency situation of its own, and it wasn't getting any better. Faced with a daily average of more than 200 patients-72,000 in a year--the pediatric facility didn't have enough places to put them or clinicians to treat them.
The average length of an emergency visit was 31/2 hours, half an hour longer than the national norm. A dozen or so families per day gave up and walked out without their child ever being seen. On a hectic day, the number of children leaving before being seen could balloon to 30 or 40, says Barbara Duffy, the hospital's chief operating officer.
But doctors already were seeing more patients per hour than they should, according to emergency medicine standards. Nursing managers often pitched in with the crush of basic nursing duties, which diverted them from their critical role of coordinating the heavy volume of patients.
Meanwhile, waits for an available hospital bed for the 10% of emergency patients who ended up being admitted took at least 11/2 hours, sometimes as long as four or five hours--keeping others in the emergency room waiting longer to get the attention they sought.
That was more than three years ago, before administrative and clinical leaders at the 268-bed hospital analyzed the many bottlenecks they found in the emergency department and opened them wide to accommodate the increased volume.
Today, the average length of an emergency visit is 50 minutes shorter than it was late in 1999, when the concerted effort to improve the operation got under way. About 1% of patients leave without being seen, compared with 5% back in 1999.
The turnaround is reflected dramatically in patient- satisfaction surveys conducted regularly by an outside firm, Duffy says. With families frustrated by delays and lagging service, the emergency department's satisfaction level sank to the 34th percentile in the third quarter of 1999. But by February 2001 it had surpassed the 90th percentile and has hovered in the high 90s ever since.
The improvements came despite an even steeper rise in annual volume than the increase that initially prompted the campaign for change. After rising to 72,000 visits in 1999 from 62,000 in 1995, volume jumped to 79,000 in 2001 and 84,000 in 2002.
The hospital is projecting 90,000 visits for 2003--25% more than the volume it struggled to handle only four years ago. But hospital managers consider themselves ready to take care of that many and already have identified a next round of moves to accommodate more, says Richard Dellerson, administrative director of emergency services.
Critical crush of ER volume
The troublesome problem list that burdened Miami Children's in 1999 could aptly describe ERs across the country today. It's a situation so acute that the Joint Commission on Accreditation of Healthcare Organizations last month proposed action to reduce ER overcrowding and lessen the dangers of treatment delays (May 19, p. 6).
The JCAHO, armed with evidence that delays and overcrowding are leading to unnecessary deaths and complications, drafted an accreditation standard that calls on hospital leaders to move patients more efficiently through a healthcare facility--with special attention to predicting and monitoring the capacity of areas that receive emergency patients.
Hospitals countered that much of the problem was beyond their control, fueled by societal factors that drove up volume at the same time that shortages of nurses and other professionals precluded adequate staffing.
During the past decade, emergency visits nationwide increased 20% to 107.5 million in 2001, compared with 89.8 million in 1992, according to the most recent figures from the federal Centers for Disease Control and Prevention. Americans became more inclined to go to the emergency room: Annual visits per 100 people increased 8% to 38.4 in 2001 from 35.7 in 1992, and the average emergency stay in 2001 stood at three hours, according to the CDC. Driving the rise in volume were nonurgent medical problems, healthcare representatives say.
"We were handling the sickest patients well," says Rodney Baker, clinical director of emergency services at Miami Children's, recalling the situation in 1999. "The backlog was for patients who had more minor complaints."
But that backlog was contributing to frequent complaints from the hospital's medical staff, including physicians in office practice who were hearing from their patients about the long waits, Dellerson says. Morale was low among the doctors and nurses in the emergency department.
The problems affected both the business and clinical reputation of the facility, Duffy says. For families experiencing delays in medical care, "the confidence level in the institution goes down as you wait," she says.
The rest of the hospital operation suffered from those problems, Duffy says, because more than half of all inpatient admissions originate in the emergency department. "The ER is our front door," Duffy says. "If 50% of our patients come through the ER, it's critical to have a system that sees patients rapidly and in an orderly fashion."
Business consequences aside, the patient-safety ramifications hit home years before the JCAHO and Institute of Medicine raised the issue, especially the problem of walking out in frustration, Dellerson says. "If you're inefficient and have extended stays, you will have people leave without being seen and that is a safety issue," he says.
Starting with a goal of reducing lengths of stay in the emergency department, Miami Children's gradually relieved the pressure of patient volume through a combination of new and updated technology, an aggressive hunt for additional space, creative approaches to increasing staff and improvement in the routines for receiving and routing patients.
Inadequate for the task
Just by comparing the ER's bed capacity and physician coverage against generally accepted standards for patient volume, hospital leaders knew they had a severe mismatch to rectify.
Using a standard of one bed for every 2,000 visits per year, Miami Children's needed 36 beds to handle the 72,000 visits it logged in 1999. It only had 24 beds, 12 short of what it needed.
A standard for safe and effective work pace in the ER called for doctors to see an average of 2.4 patients per hour, or about 19 per eight-hour shift. By that standard, 30,000 hours of physician coverage would be required during the year to meet the volume, Dellerson says. But ER doctors collectively logged 25,700 hours, more than 4,000 short of demand.
As a result, the emergency physicians at Miami Children's would have to see an average of 2.8 patients per hour to keep up with the stream of patients coming though the ER door, or three more patients per shift than the specialty's norm.
That assumes a steady flow of patients, which was anything but the case at Miami Children's. Patients with the worst illnesses or injuries were whisked into the ER, but the triage process for the rest of them was holding up the operation--including "an inordinate amount of time" taken up by registration, Dellerson says.
To take some of the load off the main ER, hospital employees diverted some of the minor cases to a department for nonurgent care, called Kidsville, but it was on the opposite side of the building from the emergency entrance, Duffy says. Assessing and routing nonurgent cases slowed down the triage process even for the sicker patients, Baker says, because someone first thought to be quite sick might not turn out to have an urgent problem.
On the other hand, delays in providing treatment combined with an inadequate assessment process created a situation ripe for missing a worsening medical condition, Dellerson says. "In every illness there's a time factor, a fourth dimension (in triage). What they're seeing at 3: 45 in the afternoon might be a whole lot different at 5: 15."
The analysis of the overcrowding problem in 2000 and early 2001 also identified delays in getting test specimens to the laboratory, ER patients into the X-ray department and admitted patients onto a nursing floor from an emergency bed.
In addition, children often waited longer than necessary for the next stage of treatment because the tracking process was lacking and the results of lab and diagnostic tests weren't brought immediately to physician attention, Dellerson says. Nurse managers often were tied up doing basic nursing because of staffing shortages, he says. "You had the proverbial intersection without a light or a cop."
Carving out capacity
Hospital managers had to gain some room to maneuver. About two-thirds of patients were coming in for nonurgent problems, inundating the main ER. "With that volume you really need enough room to get people through," Duffy says.
"We had to find some extra space, which was actually right under our noses," Dellerson says.
An outpatient clinic next to the ER had 11 rooms for evaluations, treatments and procedures. The emergency department modified seven rooms and made use of four others, which were already equipped for ER care, after 6 p.m. during the week and on weekends. The clinic found space elsewhere in the hospital.
The emergency department's busiest times are after 5 p.m., "right when the clinic is finishing up," Dellerson says. Available by the middle of March 2001, the area was promoted as a "rapid-care center" for nonurgent cases, operating between 10 a.m. and 4 a.m., with 14 permanent rooms and four part-time rooms. The waiting room for the clinic became the shared waiting area with the rapid-care center.
But soon even that expansion wasn't enough. Anecdotally, executives were hearing that the word about shorter waits was getting out to family and friends of patients and their parents. "As we began to make improvements in throughput, we continued to get volume increases, which challenged us," Duffy says.
The hospital carved out additional space for nonurgent care in an area about 40 yards from the ER where children were sedated before undergoing an MRI procedure and where they recovered afterward. "All the rooms were perfectly set up: gases, suction, all the things we needed," Dellerson says. Just as the rapid-care center relieved the crush on the main ER, the extra nine units in the MRI area--which were vacant on nights and weekends--relieved the volume burden on the rapid-care center, he says.
In the ER, an extra X-ray room, a pneumatic tube system to the laboratory and a computer interface between the lab and ER information systems all helped reduce the turnaround time for test results, Duffy says. Employees no longer were diverted from patient care to run specimens to the lab, and results immediately were flagged in the computers that doctors and nurses monitored in the emergency area, she says.
All CT and MRI scans still had to be done in the main radiology area, but basic X-rays for problems such as broken arms and respiratory ailments could be handled at the separate X-ray room in the ER, Duffy says. The hospital radiology department was next to the ER, but it had inpatient appointments scheduled all day. When all emergency business was being sent there, either someone from a nursing floor had to get crowded out or an ER patient had to wait for an opening, she says.
The total investment in renovation and construction, IT upgrades, the pneumatic tube system and the radiology room was less than $250,000, Duffy says.
Mobilizing sufficient staff
With emergency space increased and consolidated, hospital managers had to increase staff to handle the extra capacity and reorganize how patients were assigned and distributed to ER areas. "We threw a lot of people at this," says David Carroll, Miami Children's chief financial officer. The ramp-up included a 20% increase in the registration workforce. "That's what it takes to get people through the process we have," he says.
Part of improving ER access was to replace a registration routine that was taking more than 30 minutes to complete, Dellerson says. "It didn't make any sense to try and knock off the whole registration process right up front," he says. "That's the narrowest point in the process."
Instead, registration clerks took basic identification facts simultaneously with triage and handled the rest of registration after a patient was moved to a treatment room or to the waiting area, where they would have to mark some time anyway, Dellerson says.
Similar streamlining was necessary at the conclusion of an emergency visit when a patient has to be admitted, Baker says. All the speed-ups in registration, lab and radiology, he says, could be neutralized by a two-hour wait for an available hospital bed, during which doctors can't see another patient in the occupied ER bed.
Working with nursing units, housekeeping, transport workers and others, the hospital developed a plan to get ER patients transferred in less than an hour, Duffy says.
Transfers have averaged one hour recently, slowed somewhat by a high inpatient census of about 250, she says. But Baker says the situation generally is much improved. "There are many times that once the nurse is ready to admit the patient, it's 10 minutes," he says.
The larger operation placed a premium on registered nurses in short supply. To adequately staff the department, the hospital hired paramedics on their off days. They could take vital signs, start intravenous lines, apply splints and otherwise free up nurses. Also sought were licensed practical nurses, who could do everything paramedics could do, plus give medications. "We had to get to the point where nurses were doing the pure nursing stuff that no one else could do," Dellerson says.
The ER gained an additional 6,600 hours of physician coverage through recruitment and by offering independent pediatricians the chance to make some extra money. Three new emergency medicine physicians were added to the hospital-based practice for serious injuries and illnesses. For the rapid-care center, the hospital hired pediatricians for six-hour shifts at the busiest times.
Managers also identified pediatricians who had been seeing routine patients in the emergency room a long time and had enough experience to take on more urgent cases--though not life-threatening cases that required the expertise of emergency-medicine specialists. That increased the flexibility to handle whatever comes in the door, Dellerson says, not only with physician coverage but with available space.
For example, when the rapid-care center has space available and the main ER has more than the usual number of true emergency cases, some of the lesser emergency cases can be moved into the adjacent "nonurgent" area with capable physicians and facilities that can handle the problem. That ability to shift cases helps to "decompress the main ER" when necessary, and ensure that the sickest children get seen first, he says.
An upgraded patient-tracking information system identifies the location and condition of all patients. In addition, it keeps tabs on their movements through the emergency department, including how long they wait to get registered, seen by a physician, treated and tested, and discharged or admitted after the doctor is finished. That forms the foundation of a reporting mechanism that gives ER clinicians daily feedback on wait times and logjams to correct, Duffy says.
The daily report "keeps them focused on what the prize is," she says.