By Winthrop Quigley
Albuquerque Journal
Copyright 2008 Albuquerque Journal
ALBUQUERQUE, N.M. — One Monday afternoon not long ago the average patient waited between five and six hours to be treated at Presbyterian Hospital’s emergency room near Downtown, the secondbusiest emergency room in the city after the University of New Mexico Hospital.
The long wait had little to do with anything going on in the emergency room and much to do with physicians’ schedules and preferences, a national and local shortage of nursing professors, patients’ family dynamics, the insurance that skilled nursing centers operated by other companies accept, and countless other complications.
Like Jell-O sitting on a plate, if you poke a complicated system anywhere, it jiggles everywhere. Think of the air travel system: a snowstorm in Chicago creates delays in Mexico City. Hospitals are no different.
“It’s a national issue, not just Albuquerque,” said Presbyterian nursing vice president Doyle Boykin. “Almost every emergency department in the United States is having the same problems.”
On any day in the Presbyterian Hospital emergency room, about 40 percent of the people waiting have no business being there. Their condition does not require emergency care. People are sitting there for hours nursing a cough, a sore throat, a headache. A true emergency case - a heart attack, a stroke, a dangerous trauma - receives treatment in less than 10 minutes.
Part of the problem is simply that emergency departments are busier than ever. Presbyterian’s Albuquerque hospitals hosted almost 132,000 emergency department visits last year, a 63 percent increase since 2002.
The real reason for the delay, though, is found on the floors above the street-level emergency department. On that Monday afternoon, 18 of the 40 emergency room beds were occupied by people who had already received emergency care and needed to be admitted to the hospital. According to emergency department director Diane Cassell, a patient who will be admitted into the hospital from the emergency room will wait an average of 10 hours before a bed opens upstairs. People who need urgent treatment, a cardiac patient who needs catheterization, for example, are moved very quickly.
Presbyterian also tries to divert sick children from the emergency room to an in-hospital pediatric urgent care center. It frees up emergency room space and gets kids into a kid-centered clinic.
Presbyterian is spending a lot of time and effort trying to understand why getting people out of the emergency room and into the hospital is such a problem. Some of the reasons are surprising.
Just as some people don’t belong in the emergency room, some patients probably shouldn’t be in the hospital, said Presbyterian chief operating officer David R. Scrase. Presbyterian and other hospitals are looking at ways certain pulmonary and cardiac patients can be properly treated and monitored in their owns homes.
Patients can’t be discharged from the hospital until a physician writes an order. Ideally, the order is written in the morning, before the emergency room starts backing up, so the bed can be freed up for new admissions. Some physicians can’t or won’t get around to doing discharge orders until later in the day.
Some patients don’t belong in the hospital but need some additional nursing before they’re ready to go home, which is the job of skilled nursing centers. Scrase said there are not enough skilled nursing beds in the community. Limiting things further: some facilities won’t accept payment from some insurance companies or public programs. With no place else to go, the patient stays in the hospital.
A patient could be properly discharged and anxious to leave, but a family member who works during the day isn’t available to give the patient a ride home. Before last year, the patient stayed in the bed until a family member got off work in the evening. Presbyterian now offers a ride to patients who can be safely taken home so the bed can be released to another patient.
Part of the problem is competition for hospital beds. At the same time an emergency room admission is pending, physicians have been admitting patients from their practices. Some beds go to people who are being moved within the hospital from one unit to another where care levels are more appropriate.
Staffing shortages are the biggest problem. Recently, Presbyterian’s Web site listed 192 openings for nurses throughout its system. Lovelace Health System had 89 openings for registered nurses. Nursing schools do not produce enough nurses, in part because there are not enough professors to teach nurses, Cassell said. Physicians who specialize in caring for patients in hospitals are also in short supply, Scrase said.
“The easiest solution would be to build more beds,” Scrase said. But that drives up cost. Besides, said Boykin, “You can build beds faster than you can staff them.”
“We’re trying instead to use them more efficiently,” Scrase said.
Hospitals have some of the same process control problems manufacturers have, and Presbyterian has started to think of the emergency room problem the same way manufacturers think of moving materials and assemblies through a production line. Presbyterian has even adopted the Six Sigma process improvement system pioneered by Motorola and used by businesses internationally to reduce errors in manufacturing, save time and eliminate unnecessary steps in a process.
Not surprisingly, process improvement engineer Doug Johnson thinks a lot about where the time in the emergency room goes. Johnson has found, for example, that it takes four minutes to check a patient into the department and another four minutes to triage the patient.
Presbyterian found a lot of time is spent responding to physicians asking if an X-ray report is available yet. The fix: put a notification that results are available on the computer system so the physician can look for herself.
Johnson graphed when the department is at its busiest (from about 4 p.m. to about midnight) so staffing can be adjusted to meet the load. Since getting people out of beds in the hospital frees up space in the emergency room, Presbyterian is looking for ways to speed up discharge. It turns out that physicians tend to see their sickest patients first, which generally means they start with patients in intensive care. If they could get to the acute care beds sooner, where many admissions go, they could discharge patients sooner, easing the burden on the emergency room.
Presbyterian used a tool called value stream mapping on its surgical services last year and is in the process of using the tool on the emergency department. Value stream mapping identifies everything done in a unit like the surgical service that adds value to the customer and the time it takes to do it. With that information, staff can identify which processes add no value and find ways to eliminate them. In surgical services, Presbyterian discovered 64 percent of the time the patient spent in the unit added value to the patient. Process changes are projected to increase that to 90 percent of the patient’s time.