Cutting emergency department wait times as patient volumes rise

Everyone made one thing clear to Lance Porter when he arrived in mid-2014 as the new CEO of Payson (Ariz.) Regional Medical Center: The hospital's emergency department had to be “fixed.”

Patients routinely complained they had to wait more than 40 minutes to see an emergency clinician, and the staff was frustrated, too.

The level of discontent was a big concern for the 44-bed hospital. It offered the small town of Payson and the surrounding communities a wide array of services, including cardiology, orthopedics and obstetrics, but was facing serious competition from the Mayo Clinic 60 miles away in Scottsdale. That's “close enough for people to seek care there if they don't feel we provide good enough care here,” Porter said.

Last August, Banner Health acquired the hospital from Community Health Systems. Banner brought in a new physician group that worked to improve staff communication. The initiative revealed poor communication was a key factor in problems at the hospital, which was renamed Banner Payson Medical Center.

By December, waits had dropped by almost half.

“Emergency and wait are two words that shouldn't go together—it's oxymoronic,” said Dr. Jay Kaplan, president of the American College of Emergency Physicians. ED patients are distressed about acute health problems, and long waits can mean worse outcomes. In 2008, the ACEP said too many EDs were critically overcrowded, which Kaplan says remains the case.

Recommended solutions, such as registering patients at the bedside and adding personnel to “fast-track” low-acuity patients, have not been widely adopted.

That's true even as hospitals face tangible consequences for frustrating their patients. What patients relay about their experience on the HCAHPS survey figures into whether hospitals win or lose under Medicare's Value-Based Purchasing Program. And ED wait times are posted on the federal Hospital Compare website intended to help consumers choose where to seek care.

Also, visits to the ED at Banner Payson and elsewhere continue to rise even as the ranks of uninsured patients decline under the Affordable Care Act. This summer, the ACEP plans to update its 2008 report on wait times with new tools for struggling emergency departments.

At Banner Payson, staffing firm TeamHealth introduced a tool developed by the Agency for Healthcare Research and Quality known as TeamStepps, which promotes teamwork among nurses and doctors.

Poor communication is the root of much of the dysfunction in EDs, said Dr. John Toussaint, CEO of the ThedaCare Center for Healthcare Value, which advises healthcare executives about eliminating wasteful or inefficient processes. “Teamwork doesn't necessarily come naturally,” Toussaint said.

Clinicians at Banner Payson now huddle at the end of every shift to go over daily observations and cultivate team spirit. Nurses are now allowed to order routine lab and imaging tests, such as those for patients with abdominal and chest pain, so they no longer have to wait for doctors to do it.

In September, the hospital hired scribes to enter notes into electronic health records during the busiest hours so physicians could spend more time with patients.

Wait times dropped from about 40 minutes in January 2015 to 23 minutes as of last December, according to the hospital's internal reports. The time that lapsed from when a patient entered the ED to when a diagnosis was made fell from nearly four hours to less than three.

Rates did slightly increase in September, which Porter attributed to the learning curve as staff members started using the new EHR system adopted after the Banner acquisition.

But perhaps most important, patient complaints about the ED dropped from one a week to fewer than one a month. And there was less staff turnover, which meant Payson had less need to hire traveling nurses, Porter said.

While the efforts should be commended, Toussaint cautions that such changes often prove difficult to maintain if the root causes, such as processes that are designed around the caregivers and not the patient, are not addressed.

The ACEP's Kaplan makes a similar point: Accountability and follow-through are critical with any process that focuses on teamwork. “Anything that improves face-to-face communication is fabulous,” Kaplan said. “But to hold on to the changes, you have to follow through. Because sometimes a new process may last for six months and then people stop using it.”