The Patients Keep Coming
A recent study showed a more than 50% increase in patients visiting rural emergency departments (EDs). In addition to those extra patients, rural EDs have also earned the distinction of being a safety net hospital. This means the hospital has a higher ratio of uninsured, low income, and vulnerable patients. That adds a financial burden, which increases the difficulty in meeting the demand. But some strategies can help.
Preventing potential harm
When a patient leaves without being seen (LWBS), there is always a possibility that the patient will suffer later. Depending upon the illness or injury resulting in an ED visit, further harm may occur when treatment is not received. Emergency departments everywhere are searching for answers to this dilemma. The answer is found in 4 adjustments to processes and personnel.
Step 1: The wait is over
An ED must first determine a reasonable yet realistic wait time from ED entry to placement in an exam room. One study identified 20 minutes as an initial target with a secondary deadline of 35 minutes. Meeting goals requires limiting registration questions to only those needed to confirm identification and determine the reason for the visit. Triage must also include only minimal questions regarding health status to allow a quick determination of acuity.
Step 2: Help is here
No matter how processes are changed to decrease wait time, if adequate staff aren’t available, the patient will wait. Tracking of peak seasons, days, and times can assist in determining when extra staff must be available. Smaller hospitals with a limited staff roster often float staff from other departments to assist in peak times. Additionally, many hospitals benefit from remote case management teams, who can help cover triage processes during peak hours.
Step 3: Who’s next?
Triage is the process of determining who is most acutely ill and needs to be seen first. Using Physician Assistants (PAs) or Nurse Practitioners (NPs) in triage may assist with quick determination of acuity. While triage is necessary to get rapid assistance for patients with life-threatening conditions, what about the other patients? Prompt diagnosis and treatment for patients with less critical illnesses help clear the waiting room without a long wait. Some EDs also utilize a fast-track area in which less critically ill patients are placed after triage. Nurses are trained to initiate x-rays or labs to speed diagnosis. The key to this solution is having dedicated staff for the fast-track area.
Step 4: Move in, move out
The ED often becomes a holding area for patients requiring inpatient admission when a bed is not available. One suggestion for alleviating this bottleneck includes better management of inpatient diagnostics, discharges, and bed turnover. Day of release diagnostic testing and treatments must be done early or scheduled post-discharge. Transportation and post-discharge needs should be determined first, and details finalized before the day of discharge if possible.
When will the waiting end?
A long wait before seeing a physician is the primary reason given by patients who leave the ED without treatment. Part of the problem may be that people don’t like to wait. But when an illness or injury brings a person to the ED, the expectation is that the person will see a physician emergently. Unfortunately, in a likely overcrowded ED, registration, triage, placement in a room, and seeing a physician may take hours.
More can be better
Hospitals and EDs are closing, more patients are uninsured, or on Medicaid, and primary care physicians are hard to find. All that adds up to more patients visiting the emergency department. That news doesn’t have to be disheartening. With planning and appropriate actions, even small hospital EDs can manage the patient load. Focusing on what’s best for the patient and making a few process changes can result in a positive outcome for all.