Hospitals work to reduce emergency-room wait times By Anya Martin, MarketWatch In Milwaukee County, Wis.

, 48% of the 363,377 emergency-department visits last yeIndividual hospitals need to have full capacity protocols, with agreed and defined triggers. These protocols recruit support from in-patient services, focus the minds of bed managers and set clearly defined thresholds and actions. These need to be developed locally and take account of local resources. Many hospitals struggle to have enough capacity to deal with surges in emergency department activity. Flexible scheduling models for emergency department medical and nursing staff have been proposed, but often these pose problems with job satisfaction and complicate personal commitments. Emergency physicians and their administrators face an uphill struggle to engage administrators and clinicians elsewhere in the hospital to assist with emergency department crowding. Prompt discharging of patients from wards can be difficult, particularly when patients require medication to be dispensed from a pharmacy, or specialised transport services. Discharge lounges, where discharged patients can wait before transfer, help reduce hospital capacity. Early ward rounds of newly admitted patients help to match bed availability with demand. Boarding patients on inpatient wards, where a patient is sent to a full ward, to await a bed, is controversial [32, 33]. While there is a wealth of evidence that patients come to harm in crowded emergency departments, we were unable to find evidence that boarded patients come to harm on inpatient wards. This lack of evidence probably reflects that fact that the studies have not been done, rather than absence of effect. Despite this, professional bodies have consistently pragmatically endorsed boarding on inpatient wards [32, 34]. Moving only a few boarded patients from a crowded emergency department has a minimal effect on inpatient wards but has a marked and beneficial effect on the emergency department. Can we afford to continue with the current state of emergency department crowding? Will the current equilibrium shift? Is there perhaps an administrative acceptance that there will always be a queue for acute care and that the emergency department is where that will be? Policy makers and commissioners of emergency services need to consider emergency department crowding as an unintended consequence of policies and consider how they can incentivise the whole emergency healthcare system to function effectively. Emergency department crowding is an increasingly recognised problem across the world. While the evidence is clear of the harms, future work needs to systematically evaluate interventions and guide evidence-based policy. ar were non-emergent, according to Dr. Paul Coogan, emergency-department medical director at Aurora Sinai Medical Center in Milwaukee.

Theres a lot of non-urgent, non-emergent use of ERs because, lets face it, were pretty quick, open 24-7, board-certified in emergency medicine, and because of [federal] law, we have to see everybody who shows up, he said. Since starting a program in mid-2006 that matches non-urgent patients with alternate providers, Aurora-Sinai has reduced its annual ER visits by about 23%, Coogan said. That percentage might have been higher if another nearby hospital had not closed, funneling more emergency patients into Aurora-Sinai, he said. Over the last 15 years, the number of emergency departments around the nation has declined by 10%, Coogan said. To meet federal legal guidelines, all arriving patients at Aurora-Sinais emergency department are seen and triaged by a physician, nurse practitioner or physician assistant, he said. If a patient is found to have a non-emergent issue, he is educated about the appropriate use of the emergency room to reduce unnecessary future visits and then sent to a scheduler to make a follow-up appointment with an appropriate primary-care provider. We dont just kick the patient out, Coogan said. We make sure they have an appointment with a primary-care doctor in hand, and thats whether they have insurance or not. New tools help redirected patients Efforts to redirect ER patients are often criticized as not being effective because people dont show up at these follow-up appointments, but MyHealthDIRECT, the Web-based scheduling program that Aurora-Sinai uses, was specifically developed to address reasons why people might miss appointments, said Jay Mason, chief executive and cofounder of the Milwaukee-based software developer. Weve learned through the years what the important variables are, so for example, Jay lives in this neighborhood and needs to be seen tomorrow afternoon with a Spanishspeaking doctor who takes Medicaid, he said. Hospitals work to reduce emergency-room wait times

MyHealthDIRECT is being used by hospitals in seven states, and the company plans to expand to 60 hospitals in 10 states by mid-summer. MyHealthDIRECT also strives to address another criticism of ER patient-redirection efforts unavailability of doctors to see Medicaid and uninsured patients, Mason said.

You might assume that uninsured people are the greatest ER users for nonurgent issues because of their lack of access to doctors, but its Medicaid recipients who show up the most at a rate five times higher than adults with private insurance in 2007, according to the UCSF study. Last years federal health-reform law not only will insure more people but also will increase Medicaid ranks by about 16 million by 2014. While hospitals say they have nowhere to send Medicaid patients because of doctor reluctance due to low reimbursement rates, MyHealthDIRECT has been tapping community clinics. And primary-care physicians, if asked, are willing to take a specified limited number, Mason said. In 2008, the Centers for Medicare and Medicaid Services allocated $50 million in grants for 20 state agencies to establish new primary-care providers for Medicaid recipients to use for non-urgent care and to increase outreach to people who have a high rate of emergency-room visits. The original two-year grant period was extended by an additional year and just ended on April 14, 2011. States have until July 14 to submit results. CMS has several other initiatives to reduce inappropriate or unnecessary emergencyroom use and increase alternate care delivery models. However, taking non-urgent patients out of the ER only addresses one cause of the overcrowding that leads to longer wait times, said Jesse M. Pines, an emergency physician and director of George Washington Universitys Center for Health Care Quality. Other hospitals are addressing the wait-time issue by improving their processes; for example, having patients seen first by doctors rather than nurses, he said. Then people with more minor conditions who dont need tests can be discharged immediately and people who need tests can get those ordered up front and get through the system more quickly, Pines said. Some hospitals also are developing strategies to speed up bed availability for ER patients who need to be admitted to the hospital, another factor that can cause roadblocks in ER treatment, he said. Dont avoid the ER Still, while acknowledging that some ER visits may be unnecessary, some doctors worry about discouraging people from coming to the emergency room. Many studies supporting redirection, such as the one by Rand Corporation, are based on final

diagnoses not the symptoms that people present with to the ER, said Dr. James A. Duncan, medical director of the emergency department at Northwestern Medical Center in St. Albans, Vt. People dont come in saying I have muscle strain in the chest; they say they have chest pain, Duncan said. We encourage people to come to the emergency room with chest pain. If you have a severe headache, how do you know if its a migraine, an intracranial bleed or a stroke? His advice is still to call your doctor and come to the ER when you are in doubt about whether your symptoms are serious or not, especially if the complaint is chest pain, a head injury, a possible serious fracture or other injury. If you are concerned about ER wait times, some hospitals now are marketing their shorter wait times by posting online and even on billboards. ER wait times also will be reported on the U.S. Department of Health and Human Services Hospital Compare website starting in 2012.

Reaction Having been in the emergency department, made me see the importance of being knowledgeable in classifying patients, because the fundamentals of assessing a patient is a crucial skill of an emergency department nurse, having the appropriate assessment, classifying patients to the importance of their chief complaints is a must, guidelines like ABC are used to classify patients. After classifying patients, the nurse should be able to attend to the needs and treat the emergent cause of the disease to prevent any aggravating factors to add up to their illness. It is also for us to refer clients to doctors so the doctors will be able to determine the plan of care for the patient and the critical judgement will be of great use for the nurse to determine the appropriateness of every action or intervention done to the client. As it will help both the patients and also the facility the nurse should move quickly but also be cautious in performing each intervention so quality over quantity should be considered. I have learned a lot as I see that in our hospital they practice this as they provide care to each patients going in the hospital. For their critical judgement is of great use and also their proper communication helps client be relieved of their complaints.