Optimizing Emergency Department Throughput: Operations Management Solutions for Health Care Decision Makers PDF

Introduction: Description of Current Status of Emergency Departments and Hospitals

According to a June 2006 report issued by the Institute of Medicine of the Academy of Science, the emergency medical system in America is in critical condition. Across the country ambulances are turned away from emergency departments (EDs) and patients are waiting hours and sometimes days to be admitted to a hospital room. Hospitals are finding it hard to get specialist physicians to come to treat emergency patients.¹ Our emergency medical system is at a stage where it cannot support the public's demand for care.

In the decade leading up to 2006 the country saw the annual number of visits to EDs rise by 32% to 119.2 million visits. This equates to an annual increase of 3.2%.2 Like economic inflation, society's need for medical attention is eating into our medical wealth at a rate that cannot be sustained. Making the situation worse in the same period that utilization was increasing markedly, the number of EDs available to meet this growing need fell from 4,019 to 3,833. Adding to the stress, the number of visits per person increased by 18% from 34.2/100 people to 40.5/100. So, not only is the absolute number of visits rising and places to treat this growing demand falling, but society is using the service more frequently. We are more dependent upon this resource as a society than ever before and the pressure is growing.

A common discussion among ED professionals is the perception that many patients are not really emergency patients and could be treated in another setting at another time. A National Center for Health Statistics report supports this in that only 10.8% of visits are truly emergent (needing to be seen within 1 to 14 minutes).² However, another 36.6% are urgent (needing to be seen within 15 minutes to an hour). Semi-urgent patients (needing to be seen within 1 to 2 hours) represent 22% of all patients seen in EDs nationally. Nonurgent and unclassified represent the remainder, about 30% of visits. In other words, over half of all patients presenting for care in EDs could indeed be treated in alternative settings and arguably for less cost and in shorter time. Over the years these numbers have generated an ongoing discussion of how to redirect patients. This topic is discussed later in the book.

Although the majority of patients waited less than an hour to see a physician (61.8%), the median patient care time was 2.6 hours. Between 1997 and 2004, the median wait time for heart attack patients increased 150 percent from 8 minutes to 20 minutes.³ We all have examples among family and friends that fall well outside these averages. Again, that is only the average.

The time of arrival in EDs is a much studied and discussed issue. Nationally, the lowest patient volume is seen in the early morning (5 a.m. to 6 a.m.), while the highest volumes are seen in the early evening between 6 p.m. and 9 p.m. The difference between these times is about a multiple of 3. This is probably no surprise to anyone involved in the business, as it seems to correlate closely with our lifestyles. People are occupied with school and work during the day and may seek care at more convenient times. It also correlates closely with the availability of traditional physician office hours. In fact, EDs provide about 11% of all ambulatory care in the country, which is interesting given that emergency physicians represent only 3.3% of all active physicians.

Nationwide, EDs are under growing pressure to treat more patients in fewer facilities resulting in overcrowding, patients waiting to be seen, patients lying on gurneys for hours waiting for discharge, and patients boarding in hallways awaiting inpatient beds. While these patients are being subjected to long waits, hospitals are consuming very expensive resources in an inefficient manner. Not to make too fine a point of it, we have all read the horror stories of patients dying awaiting care.

The financial condition of hospital EDs is a hot topic among managers in many hospitals. The uninsured represent 17.3% of all patients treated in EDs nationally but this varies greatly by individual facilities. The largest percentage of patients, at 39.7%, have private insurance, while Medicaid and State Children's Health Insurance Program (SCHIP) covers 25.5% and Medicare covers 17.3%.

Going forward there does not appear to be a quick solution. And it may get much worse before it gets better. We are facing a massive increase in the number of people who will be classified as elderly. The baby boomer population will be entering the market as elderly beginning in 2011. Already the percentage of people being seen in EDs and classified as immediate or urgent is at 24.6%. This can only be expected to increase the stress on EDs as more acute patients enter the system.

All of this said, a 2003 report authored by Paul Breslin, of Noblis, noted that EDs accounted for the greatest percentage of hospital admissions.⁴ EDs also were the largest source of inpatient lab tests (67%) and radiology exams (75%). In the 2006 National Center for Health Statistics report, the percent of admissions was 50.2% nationally.² This would indicate that most hospitals are almost totally dependent upon their EDs for their economic survival, regardless of payer mix. Hospitals may wish, from an economic perspective, that the ED would go away, but as a practical matter, it is their lifeline.

In summary, our country's EDs are stressed to the breaking point. Originally, EDs were established to care for the true emergency in an era when health care was much less sophisticated and our society less demanding. As now structured and organized, our EDs today can no longer handle the demands being placed upon them. Our society is demanding care, quality, and service. The health care industry would be naive to believe that there will be help coming from outside to resolve this problem. We can be sure that the external pressures will continue to increase until the pain is so great that we make the changes ourselves or face the consequences.

Focusing on ambulatory care, particularly the ED, is a relatively new phenomenon and requires a paradigm shift in thinking. The specialty of emergency medicine has only been around since the mid-1970s. EDs, as we now know them, are generally less than 40 years old in many communities. Up until now many hospitals considered the ED a necessary community service offered only grudgingly. It is now being recognized as a core service, but one that is structurally flawed having been designed for a different time and market.

Our EDs demand a new way of thinking. They are not at a tipping point; they are at a breaking point. Under current loads and trends they are going to begin to break and these breakdowns will be painful and ultimately dangerous to society.

It is not enough to simply restructure our existing system; we will need to consider a wholesale restructuring of the way ambulatory care is provided with new delivery models and greater use of technological solutions. We must make our existing system more effective. Business as usual will not suffice. Hospitals must make the system function better. This will require the utilization of more scientific methodologies to manage the system and improve efficiencies. It will require a new way of thinking.

Improving efficacy requires change, and change is not a comfortable exercise for either the individual or the organization. Creating an organizational culture that can accept and embrace change is the role of leadership. Leaders must begin the process of creating a culture accepting of change and focused on productivity.

Layered on top of all of this is the fact that EDs are the foci for health care services in the event of a disaster. The terrorist attacks of September 11, 2001, made this entirely too clear. Communities across the country look toward hospitals and their EDs for critical health care services in the event of a pandemic, natural disaster, or terrorist attack. The fragility and lack of capacity are not up to the demands of anything out of the ordinary. The ordinary is breaking them already. Health care leaders must step up to the leadership role and begin addressing how community hospitals will provide critical infrastructure services in the event of an untoward occurrence.

The purpose of this book is to provide health care leaders tools they can utilize to optimize the performance of EDs and thereby improve service to patients, employees, and communities. The techniques described herein can be utilized to quantify improvements, enhance predictability of workflow, and improve staff scheduling. The data derived using these techniques can serve as powerful evidence in support of making change.

1. Future of Emergency Care, Institute of Medicine, June 14, 2006, Washington, DC.

2. Pitts, Stephen R., Richard W. Niska, Jianmin Xu, and Catharine W. Burt. August 6, 2008. National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. National Health Statistics Report, no. 7. Hyattsville, MD: National Center for Health Statistics.

3. Andrew Wilber et al., Health Affairs, 2, January 15, 2008.

4. Paul Breslin, The British Review, October 2003.