The ED As A Mirror
It is often said “the ED is the front door of the hospital”. But in truth, the ED is a mirror reflecting your hospital. What ails the hospital is evident in the emergency department and can be assessed by a brief survey of staff and a walk through during peak times. Consider this:
- Capacity: If any unit in the hospital is either inefficient, overtaxed or understaffed, where do those patients end up holding? They hold in the emergency department. Data reviewing types of holds by diagnosis or assigned inpatient location will quickly tell you which units are having problems.
- Staffing: If ancillary services like lab and radiology are understaffed, admitting teams begin to order tests to be conducted in the ED prior to patient transfer because there are lengthy delays otherwise. How does that manifest in the ED? Patients either wait long periods after a bed is clean and ready, or a request for a bed is delayed until orders are completed. That equates to lengthy periods of time that admitted patients spend in the ED after consultations and bed assignments. A quick survey of the primary admitting teams or physicians will tell you if this is a problem. Commonly the admitting physicians will say that the ED stat lab or stat orders are processed far quicker than any others and they are frustrated by delays, so their answer is to order everything stat and ask that it be completed before transfer out of the ED.
- Medical Staff Behavior: If there members of the medical staff who constantly do not return pages in a timely manner, who refuse to see patients in the ED, or who are argumentative and rude to staff, patient care is negatively impacted each time they are on call. How? Consultations by staff are deliberately delayed and patients wait longer for the specialist to arrive resulting in long lengths of stay in the ED. Worse, patients may be discharged home for outpatient follow up specifically to avoid consulting the physician with the problem behavior.
- Transfers: Transfers out increase when call coverage is lacking or ED physicians are not being supported by existing coverage. Also transfers in will hold in the emergency department when inpatient beds are limited.
- Culture: Complacency is a learned behavior. When middle management models that behavior to ED staff, it is typically because it has been modeled to them. How does that manifest itself in the ED? Staff don’t bring issues to light because they do not believe anything will be done to fix them. No one works to improve processes and inefficiencies. Patients ultimately suffer as throughput times increase and wait times balloon.
- EMS: As issues above worsen, patient transfer times from EMS stretchers to ED stretchers worsen as well. How does that effect the ED? EMS crews have lengthy off load times and long waits with patients in the ED. Eventually, EMS reduces patient transports to that ED or worse, diversion is used as a tactic to compensate.
The next time someone complains about the emergency department or voices frustration with its performance, stop and ask a few questions about the true source of the problem. You will be surprised at the how well the ED behaves as a mirror.