The King’s county hospital in Brooklyn, N.Y. has several claims to fame; It was the site of the first open-heart surgery performed in New York State; Kings County physicians invented the world’s first hemodialysis machine, conducted the first studies of HIV infection in women and produced the first human images using magnetic resonance imaging (MRI). In addition, Kings County was named the first Level 1 Trauma Center in the U.S.
It is ironic then, that the hospital became the center of all media attention for a negligence death in their waiting area in the Emergency Room. Esmin Green, a 49 yr old psychiatric patient had been waiting in the emergency room for more than 24 hours before she toppled from her chair and fell on ground. Although the waiting room was occupied by other patients, a security guard, and a staff member, no one cared to help Green until more than an hour after her fall (Check out the Associated Press report for further details on this).
Isolated incident or alarming trend?
HealthCare Management decided to do some research of our own and here is what we came up with.
An archived article in New York times talks about Federal regulators reprimanding cook county for serious flaws in how it decides who should receive emergency care and for treatment delay
The king’s county hospital’s emergency room sees about 116,000 patients a year
In 2007, Kings County hospital deployed, MediKiosk software solution, that automates patient registration and helps emergency department staff prioritize treatment based on medical urgency
According to a recent survey conducted by the American College of Emergency Physicians (ACEP), 80% of the 328 emergency departments surveyed board psychiatric patients
30% of ACEP surey respondents said they board patients between 8 and 24 hours
Before, we conclude it is a dead end, let us look at some other facts that might present solutions
85% of the doctors in the ACEP survey said that wait times for all emergency patients would improve if there were better psychiatric services available.
More than 80 % agreed that regional dedicated emergency psychiatric facilities nationwide would work better than the current system for dealing with psychiatric emergency patients.
Maybe, it is time to redesign the Emergency care ? We rest our case, now you decide!
British Healthcare system
The National Health System(NHS) is the publicly funded healthcare system in the UK. The NHS provides the majority of healthcare in England, including primary care (such as general practitioners), in-patient care and long-term healthcare. NHS hospitals are increasingly competing with other private health systems and facing financial difficulties.
Lean applied in Birmingham Heartlands hospital
Recently, the NHS health system and other health systems have adopted ‘lean principles’ that evovled from the Toyota production system to reduce waste. They are primarily focussing on clinical areas such as emergency departments but plan to use it ancillary areas, pharamcy and other support functions.
They have also come up with innovative solutions such as using Nurse practicioners in the ED to treat low acuity patients . They have been able to reduce the number of patients waiting from over 40 to less than 10.
With over 65% of America’s Emergency Departments reporting capacity issues, diverting ambulances has become common place. “To divert or not to divert?” is the questions often facing managers and administrators. Let us examine some quick facts.
According to the AHA in 2007, over 56% of Urban hospitals reported diversions in 2007 (above)
Lack of staffed Critical care beds was cited as the number one reason for ambulance diversion
On average, approx. 15.5% patients arrive via ambulance
Is zero diversions possible?
With about 34 ambulances being sent to EDs around the US every minute, most administrators, even state and county officials have settled into status quo in most places. But there are some well documented and concerted efforts being made by a few EDs. Which brings us to the question, Is it really possible to have Zero diversions. The answer is a resounding Yes!!!. And this has been proven by Seattle’s best (no not the coffee company) . A policy has been passed in King County, WA to enforece zero diversions in Seattle area Emergency departments. The policy requires critically ill patients to be taken to the ‘hospital of their choice’ or the nearest hospital.
Facts from Seattle’s Zero Diversion policy
Hospital administrators agreed that throughput is a hospital problem not an ED problem
Setting guidelines and on pre-diversion targets is the key to reducing diversions
If a hospital is overloaded they can go on “ED saturation” two hours at a time and then get back to green and can only do this for a total of six hours in every 24
Rearranging staff for low and high acuity has helps tremendously
Reconfiguring the alert system is critical when changes are implemented
According to the Center for Disease Control, the number of ED visits increased from about 96.5 million to 115.3 million in the United States from 1995 to 2005. This amounts to a sharp 20% increase. While this happened, the number of EDs themselves dropped from 4,176 to 3,795. With 219 ED visits per minute in the US during 2005, the ED overcrowding problem has slowly become a nationwide phenomenon. And like with other macro trends, this will replicate itself in other countries as well (if it has not already). In the fastest developing economies (like India and China), this might come sooner than expected. We will examine this and other ED practice trends in future articles. But for now, let us see what some of the best Emergency departments have been doing.
Slicing the Volume Pie
Best practice EDs address the ED overcrowding problem in 3 steps. Seperating out the flow of Urgent vs Semi urgent and Non urgent is the first step in improving flow as over 33% of the patient traffic in EDs is usually of a semi urgent or non urgent type according to the National Hospital and Ambulatory Medical Care survey. Identifying strategies to then take care of these patients in a timely manner is the second step.Setting up efficient Admitting and discharging mechanisms is the third step.
10 Best practices in Emergency Departments to facilitate better Patient Flow
1. Fast track or Urgent Care system for less acute patients
