April 6, 2013

Columbia’s Palmetto Health dramatically cuts ER waits

Midlands area hospitals work to untangle the emergency-room process.

An ambulance brought a groggy Henry Loyd to the Palmetto Health Richland emergency department Friday after his lunch hour had been ruined by another driver slamming into his car.

About three hours later, he was surprised by how quickly he had been put in a room and examined, taken to radiology for a CT scan and, after the scan was read, given the OK to head home.

“I was constantly going through the process,” said Loyd, 62, of Elgin. “There was no waiting.”

That comment is testament to the success of a redesign of a department where “I’m sorry for the wait” had become the employee mantra.

Nobody’s happy to need emergency services in the first place. Waiting for several hours to get those services can turn frustration into outright anger. The negative emotion at Palmetto Health Richland wasn’t limited to the patients and their families. Even the workers smoldered under the surface.

“The night shift used to walk through the door and see the backup in the lobby and think, ‘Oh my gosh! We have to clean up this mess from the day shift,’” said Allison Turnley, director of emergency services at the hospital. “That doesn’t happen anymore.”

After decades of doing things the same way it always had, Palmetto Health took a critical look at its procedures. The volume of patients – the emergency department treated 87,000 patients last year – long ago overwhelmed the old system.

“We knew we needed to do something different,” Turnley said. “Waits of 18 hours were not uncommon. People were leaving without seeing doctors.”

After three months, the streamlined system has cut the average wait to see a physician from 74 minutes to 22 minutes while increasing the average number of patients treated each day from 248 to 271, according to Palmetto Health. About 10 percent of emergency patients used to leave without even seeing a doctor. Now that’s down to 1.4 percent.

The emergency department staffers are astounded at how well the changes have worked.

“The first couple of weeks, you’d walk out here (into the waiting room), and it would be eerie that there was nobody out here,” said Diane Savage, an assistant nurse manager for the department.

“We’ve had people mad because we discharged them too quickly,” Turnley said. “They told family members to go shopping instead of waiting for them.”

One story already has become emergency department legend: A Highway Patrol officer came to the front desk a few weeks after the new procedures were put in place. He realized a traffic accident victim had left his driver’s license behind in the patrol car.

“He’s already been seen and released,” the person at the desk told the officer.

“No way,” replied the officer.

The desk worker looked up the records and found the patient had been seen and released in 16 minutes.

That never would have happened before the procedural overhaul.

What do we need to change?

Under the old system, a patient would have been given paperwork to fill out.

The registration employee then would punch that information into a computer.

Then the patient would be told to sit down in the outer lobby and wait to be called.

Once called, patients would go to a triage room where a nurse might come in and ask why the patient was there and determine whether they could wait some more or needed immediate attention. Often there was a long wait even in the triage room.

Then came a series of waits in the examination room as nurses, doctors and others did their jobs. The process almost seemed designed to be slow.

Turnley suspects some triage area workers thought: “Let me take as much time as I can because I don’t have a room for you anyway.”

Looking back, it’s amazing what a few tweaks can accomplish. The hospital administration brought in an outside facilitator with experience in healthcare settings. The facilitator gathered a mountain of data from people at every step of the emergency department process – who patients were, what they were being treated for, how long each process took and how long each type of treatment took.

The details of each step were put on 3 X 5 cards, then attached to a wall in a large meeting room. The 35 employees from 18 departments on the redesign committee who gathered to come up with solutions were amazed by the number of cards, and especially the number of pink cards used to note that the patient was waiting.

“We mapped out the processes they were doing, and it was frightening,” Turnley said. “We had processes where they would wait that weren’t really necessary. We came away thinking, ‘Oh my gosh, this is horrible, and we’re doing it to people.’”

The employees then suggested improvements. The only limitations on their ideas: There were no plans to add new staff or new space, and only minor equipment changes were expected.

The eventual changes in the system are too numerous to detail, but some of the biggies involved changing the check-in process, eliminating a major triage step that was mostly duplicative, setting up a radiology lab specifically for emergency cases and changing the labeling system to give other emergency lab samples a priority.

“We actually had a funeral for triage,” Turnley said. “We had a cake and everything.”

The change meant 10 rooms previously used for triage could be converted to treatment rooms. Five other rooms that had been available as treatment rooms only 12 hours a day were converted to 24-hour use.

Complaints cut tremendously

People who have visited the emergency room before will notice the changes as soon as they walk through the doors and are greeted by a nurse standing at a computer station.

The nurse asks a couple of basic questions – why you’ve come to the emergency department, and what your symptoms are – but doesn’t take vital signs such as temperature or blood pressure.

Those with the most serious problems head straight to the hospital’s separate trauma center. Other patients take a step to the left, where a registration staffer will ask name, birth date and address, then create an identifying wrist band for the patient to wear until discharge.

Assuming one of the 65 rooms is empty, the patient then is escorted straight to the examining room. In the past, new patients sat in the outer waiting room, sometimes for hours. Since the changes, the maximum number of patients in the outer waiting room has been 15, Turnley said.

It’s nearly as common, however, that the only people in the outer waiting area are family members. If there’s a wait, the patient will be asked to take another couple of steps to the left, to a cubicle where a nurse takes a first reading of basic vital signs.

Once the patients are in the examining room, a physician-and-nurse team now see the patient at the same time. In the past, those visits usually were separate, often forcing the patient to answer the same questions multiple times.

Under the old system, once patients entered a treatment room, that room was theirs until they were discharged. The average stay in the examining room was 4½ hours.

Now, if patients are waiting for the results of an X-ray or blood work, they are sent to a separate diagnostic waiting area. That frees up the examining room for another new patient.

“No. 1, it helps to see people fast,” emergency physician Dr. Stephen Ridley said of the change, “but also it’s more satisfying for the patients. It’s nice to walk into a room that doesn’t have an angry patient. They’re not at wit’s end before you even see them.”

Ridley believes the key to the redesign was the complete buy-in from all departments in the hospital, from administrators to physicians to nurses to labs. It truly marked a systemic change.

The emergency department at Palmetto Health Baptist, Palmetto Richland’s sister hospital, just went through a similar redesign effort. In two weeks, Baptist’s average time from check-in to physician dropped from 66 minutes to 31 minutes, according to Jeanne Cavanaugh, director of the department.

The new procedures at Palmetto Richland have meant a slightly busier work schedule for the emergency department staff. They aren’t waiting for bottlenecks to clear like they did in the past.

“When they knew there were 40 people in the lobby, that caused stress and strain. Now the stress and strain is moving them through the system faster,” Turnley said.

And now, patients are thanking them for treating them so quickly. Patient complaints have been cut tremendously. Before, almost 99 percent of the complaints were about waiting, Turnley said.

Of course, there still are complaints. The 22-minute wait to see a physician is an average. There still can be long waits on busy days at various steps along the process.

But on Friday, which staffers said was a relatively busy day, Loyd went through the system so quickly nobody was there to take him home. He had to call somebody to come pick him up.

The success of the redesign has been so swift and so complete, the question emergency department workers get most often is: Why didn’t you do this earlier?

“We’ve asked ourselves that a thousand times,” Savage said. “We didn’t recognize the problems until we stepped back and took a good look.”

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