Patient Safety: How to Improve the Patient Handoff Process

The patient handoff process is one of the most critical moments for patient safety in an emergency department. When emergency medical services personnel arrive at your door with a patient, challenges will arise, and an appropriate response by Emergency Department staff is necessary for a successful handoff.

When it comes to an EMS-to-ED handoff the greatest challenges lie in communication. There’s an increased potential for miscommunication — or lack of communication — that can have dire consequences for the patient.

Researchers recently evaluated 90 patient handoffs, studies of which have been limited when it comes to components of quality care. Looking at communication between EMS personnel and ED staff during the handoff, researchers found that EMS personnel provided ED staff:

• Information related to the patient’s chief concern 78 percent of the time;
• A description of the scene in 58 percent of all handoffs;
• A complete set of vital signs in 57 percent of instances;
• A description of physical exam finding for 47 percent of patients;
• An overall assessment of the patient’s clinical status in 31 percent of cases.

Researchers did note that handoffs between certified paramedics and ED staff resulted in higher instances of communication of vital signs and physical exam findings, and that paramedics offered an overall assessment more than twice as often than other levels of EMS staff such as EMTs.

This study confirms that there is significant room for improvement during the handoff process of critically ill and injured patients, researchers concluded.

So how can the process be improved in order to provide patients with the high quality of care they expect from EMS providers and ED staff?

Another study looking at this same topic found that EMS providers often saw themselves “as advocates for their patients during the challenging EMS-to-ED handoffs.” And they, in turn, offered four strategies for improving the handoff process, some of which address issues related to communication, while others addressed EMS and hospital protocols that make handoffs more challenging.

Tactics EMS providers suggested include:

1. “Communicate directly with the ED provider responsible for the patient’s care.”
2. “Increase interdisciplinary feedback, transparency, and shared understanding of scope of practice between out-of-hospital and hospital-based providers.”
3. “Standardize some (but not all) aspects of the handoff.”
4. “Harness technology to close gaps in information exchange.”

While these solutions offered by EMS providers have the potential to be effective ways to improve the handoff process between EMS and ED providers, buy-in would be necessary from the ED standpoint.

Do you think these solutions are reasonable? What can emerFgency departments do on their end to help facilitate a safe, high-quality handoff experience for patients? I’d love to hear your thoughts. Comment below or feel free to drop me a line.

Sources:

Prehospital Emergency Care: “Quantitative Analysis of the Content of EMS Handoff of Critically Ill and Injured Patients to the Emergency Department.”

Annals of Emergency Medicine: “Optimizing the patient handoff between emergency medical services and the emergency department.”

Do Return ED Visits Signal Lower Quality of Care?

When a patient makes a return visit to the emergency department, you may draw the conclusion that quality of care the first time wasn’t great. But a study recently published in the Journal of the American Medical Association offers data that may contend otherwise.

The study’s authors acknowledge that return visits to the ED “are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care.” So they set out to find whether or not these return visits, which led to in-patient admission, were evidence of a lower quality of care from the ED that initially treated the patient. The pervading question being, that if a patient is ultimately admitted to the hospital, shouldn’t it occur during their first visit to the ED, and not the second or third?

Researchers looked at in-hospital mortality, intensive care unit admission, length of stay, and inpatient costs to determine whether a patient returning to the ED was a reliable measure of quality of care within that ED. The results were surprising.

“Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay,” researchers concluded. “These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.”

Let’s look closely at the numbers. Patients discharged from an ED and subsequently admitted to the hospital upon a return visit experienced:

• An in-hospital mortality rate of 1.85 percent vs. 2.48 percent for those patients admitted during their initial visit to the ED.
• An ICU admission rate nearly six percent less (23.3 percent vs 29 percent).
• The cost of care for these patients was also less ($10,169 vs. $10,799), even though their length of stay was slightly higher (5.16 days vs. 4.97 days).

And for those patients admitted to the hospital within 14 and 30 days of their ED visit? Similar outcomes were experienced.

But what about those patients readmitted to the hospital after hospital discharge and a return visit to the ED?

“In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit,” researchers found.

What do you think? Are return visits to the ED an adequate measure of quality of care? Please comment below or feel free to drop me a line.

 SOURCES:
The Journal of the American Medical Association: “In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department”

Opioids: Which Intervention Works Best in EDs?

Emergency departments are on the front lines of the opioid epidemic. EDs have everything to gain by doing more than just stabilizing patients or denying prescriptions. A more proactive approach can not only help the patient but can improve long wait times, overcrowding and low patient satisfaction.    

EDs can begin the intervention process for patients presenting with symptoms of opioid dependence. A study published last year in the Journal of the American Medical Association looked at three interventions and their efficacy.

3 Intervention Approaches and Their Effectiveness

1. Referral
This study involved over 300 opioid-dependent patients at an urban teaching hospital, each randomly assigned to three types of intervention, and studied over the course of 30 days. After screening, this first group was provided a handout with names, locations and telephone numbers of local treatment services, which varied by type and intensity. Patients were also allowed to call a clinician or treatment facility of their choice from the ED. By merely providing patients with information and tools for treatment, researchers saw that 37 percent of participants were engaged in addiction treatment at the 30-day mark.

2. Brief Intervention
In this group, patients received a brief negotiation interview (10 to 15 minutes) from a research associate containing four components:

•      Raise the subject.
•      Provide feedback.
•      Enhance motivation.
•      Negotiate and advise. 

Treatment options were then discussed, with similar information provided that those patients in the referral group received. With this more focused intervention, 45 percent of patients were engaged in addiction treatment at the 30-day mark.

3. Buprenorphine Treatment
In this final group, patients received the same brief negotiation interview as those in the brief intervention group received. If symptoms of moderate to severe opioid withdrawal were apparent, then ED-initiated treatment with buprenorphine was started. Patients were given enough medication to take home until an appointment in the hospital’s primary care center, when a 10-week course of treatment of buprenorphine was introduced. At the conclusion of the 10 weeks, patients continued treatment in a community program, clinician-lead program or a two-week detox program.

At day 30, 78-percent of patients were still engaged in addiction treatment and illicit opioid use dropped from 5.4 days per week, to just under one. (The referral group saw a reduction of illicit opioid use to 2.3 days per week and the brief intervention to 2.4 days per week.)

All three interventions increased engagement in treatment for opioid-dependent patients, but it’s clear a more intensive, hands-on intervention with medication treatment offered to this study’s third group proved more effective. The authors say that there still needs to be more studies.

Does your ED have an intervention strategy it implements for opioid-dependant patients? If so, I’d love to hear about it. Please comment below and share what has or hasn’t worked for you or feel free to drop me a line. If you’d like an assist with fine-tuning your ED's operation, no matter which challenges you’re facing, check out my company’s website to see if we may be a fit for you.

SOURCE:

The Journal of the American Medical Association: “Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence.”

How Patient Obesity Affects Emergency Departments

The Centers for Disease Control and Management describes obesity in three words: Common. Serious. And costly.

Nearly 80 million adults in the United States are obese and the list of adverse health effects related to obesity are long — think heart disease, stroke and type 2 diabetes, to name a few.

And the cost? According to the CDC, the healthcare costs associated with obesity was nearly $147 billion in 2008.

In emergency departments across the U.S. patient obesity presents an array of challenges for doctors, nurses and staff who manage care. Physical exams are more challenging as rolling the patient is more difficult, and examining the patient’s whole body can be difficult.

A study published in Emergency Medicine Australasia concurs, noting that when treating obese, and morbidly obese patients, measuring blood pressure, inserting IVs, positioning patients and performing other medical procedures are all increasingly hard.

“BMI most strongly correlated with difficulty in finding anatomical landmarks, venous pressure measurement, physical examination, patient positioning and procedures generally, especially cannulation and venipuncture,” the report concludes.

EDs, doctors, nurses and staff have countered these challenges with common sense solutions. EDs turn to things such as lifting equipment; larger blood pressure cuffs and beds; and increased staff to help with mobilization and positioning. While these extra initiatives come with a price tag, they all are necessary to provide the quality of care patients who are obese deserve when visiting the ED.

However, surprisingly, whether patients are obese or not may not have a serious impact on average length of stay. In a 2005 study published in Academic Emergency Medicine, researchers were surprised to find that obese patients and non-obese patients presenting to the ED with abdominal pain had similar experiences:

• Length of stay for obese patients was 457 minutes, while non-obese patients LOS measure higher at 486 minutes.
• 3.2 laboratory studies were conducted for obese patients versus 2.9 for non-obese patients.
• Rates of consultation were four percent less for obese patients
• Admission rates were six percent lower for obese patients.

Does this surprise you? What strategies has your ED implement to better treat patients who are obese? Please comment below or feel free to drop me a line. 

Sources: 
Centers for Disease Control and Prevention: “Adult Obesity Facts.”

Emergency Medicine Australasia: “Obesity significantly increases the difficulty of patient management in the emergency department.”

Academic Emergency Medicine: “Obese patients with abdominal pain presenting to the emergency department do not require more time or resources for evaluation than nonobese patients.”

How EDs Can Limit Chronic Visits by the Homeless

A few weeks ago I wrote about how homelessness is one of two top causes of ED overcrowding. Today, let’s take a deeper dive into what experts think may help.

A recent study published last year in Psychiatry Services, a journal of the American Psychiatric Association, followed a cohort of more than 700 homeless individuals over a three-month period, tracking their use of the ED. Over the course of the study, 30% of participants visited the ED one or two times, while 12% visited three or more times, which researchers deemed “high use.”

What researchers determined was that the reasons behind chronic ED use by the homeless were complicated.

Surprisingly, researchers concluded that housing status didn’t play a large of a role in chronic ED use. Homelessness wasn’t a cause in itself. Also, outside services did little to stem visits. However, the situation isn't totally hopeless. They found a possible solution lies in the cooperation of vested interests.

They contend that more coordination between outside services, housing organizations and healthcare providers “may better address the complex medical, housing, and psychosocial needs of chronically homeless individuals.”

“Increased ED utilization was associated with both general medical and psychiatric morbidity and greater use of non-ED services,” researchers wrote. “Thus ED use was related to high need and acuity and was not ameliorated by use of other services.”

So what does better coordination look like? Two recent news stories highlight how EDs and hospitals can better coordinate care with outside organizations to decrease ED use by homeless individuals. While these initiatives appear to be working, it’s still too early to gauge whether they’ll be sustainable in the long-term. But what they do show is how cooperation between outside organizations and healthcare providers can lead to better outcomes for homeless patients.

Finding respite in old motels

“It’s impossible for homeless people to recover from a health crisis when they just go back out onto the street after being discharged from the hospital. They end up returning repeatedly to emergency rooms and hospitals, which are very expensive.”

This story out of Buena Park, CA is a wonderful example of how coordinated care for homeless patients can better serve these individuals and positively impact a hospital’s bottom line.

The Illumination Foundation, a homeless services non-profit, has converted an old motel into a place of refuge for recently discharged patients. A triage center has been set up in the lobby and the rooms have been transformed into recovery facilities, with funding assistance provided by area hospitals and health insurers. Patients stay between two to three weeks and are able to obtain the social services necessary to help move them into more permanent housing. A nurse is even on staff.

And the program, still in its early stages, appears to be cost-effective—to the tune of $2,000 less per day than a hospital stay, which saves hospitals and insurers money. Patients, too, are experiencing positive results.    

“Housing first style” housing

“The hospital is paying to get them out of the emergency room and into housing.”

In Chicago, the University of Illinois Hospital has partnered with the Center for Housing Health to provide homeless patients an apartment and a case manager in order to curb chronic ED use. And it seems to be working.

Case managers help coordinate care by scheduling follow-up appointments, which lessen the odds of a return visit to the ED; and the apartments — which cost the hospital a third of what a hospital stay would — lessen the burden of homelessness on the patient and the healthcare system. And that’s not all. So far, with 15 patients in the pilot program, the initiative has helped lower healthcare costs for these patients by 75 percent, while having a positive impact on their health.

What these two programs highlight is how high-quality care doesn’t have to come at the expense of a hospital’s bottom line. What’s evident, is that investments in long-term solutions for the homeless and coordination of care pay off. Hospitals are able to increase the quality of care for all its patients — not just its chronic users who suffer from homelessness or mental and substance abuse issues — and cut costs.   

Is your hospital or ED working with an outside organization, or has a cutting-edge initiative it’s employing to counter the chronic use of the ED by the homeless? I’d love to hear about it. Feel free to comment below or drop me a line.

SOURCES:

Psychiatry Services: “Factors Affecting Emergency Department Use by a Chronically Homeless Population”

Kaiser Health News: “Old Motels Get New Life Helping Homeless Heal”

Texas Public Radio: “A Hospital Offers Frequent ER Patients An Out — Free Housing”

Why Higher HCAHPS Scores Don’t Always Mean Improved Quality of Care

The most satisfied patients aren’t always the ones receiving the highest quality of care. It may seem counterintuitive, but recent studies and news articles suggest that a patient’s level of satisfaction doesn’t strictly correlate with the quality of care they receive.  

Since the inception of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which measures patient satisfaction and influences Medicare reimbursements to hospitals, healthcare providers have placed extra emphasis on their patients’ happiness. Some hospitals have gone as far as implementing valet service, hiring door greeters and even adopting loyalty programs, all in an effort to please their patients. While a nice touch, these added “amenities” offer little when it comes to actual quality of care. 

Hospitals will soon begin to measure satisfaction among patients within their emergency department with the Emergency Department Patient Experiences with Care (EDPEC) Survey. And just as with their inpatient population, hospitals will face financial repercussions if their ED patients are left unsatisfied. 

When it comes to this new survey, emergency departments will find the greatest cause for concern in regards to their patients’ perception of pain management. Specifically, these three questions:

• During this emergency room visit, did the doctors and nurses try to help reduce your pain?
• During this emergency room visit, did you get medicine for pain?
• Before giving you pain medicine, did the doctors and nurses describe possible side effects in a way you could understand?

If the inpatient experience is any indicator, patients suffering from acute and chronic pain may be disappointed to find that the pain medication they believe they urgently need will be prescribed sparingly or withheld altogether. 

With the growing opioid crisis in the country, many EDs are instituting strict guidelines when it comes to prescribing these narcotic pain medications. They’re turning to alternative therapies, such as acupuncture and even laughing gas, which have proven effective and have less dangerous side effects—think addiction, overdose and death. 

Even with alternatives some patients are set on receiving pain medication, regardless of the consequences. And if they don’t receive them, or are prescribed a limited quantity, the likelihood they’ll express their dissatisfaction in the EDPEC survey will be great. 

In many cases related to the management of pain, quality of care will come at the expense of patient satisfaction. When it comes down to it, the patient’s perception of the quality of care they receive isn’t as important as the reality of the care they receive. However, Medicare reimbursements may be in jeopardy as a result. 

I believe this short quote from The Atlantic sums up the dilemma hospital and ED leaders face:

"Patients can be very satisfied and be dead an hour later."

What do you think? What strategies have you implemented to increase patient satisfaction? Are you confident these strategies aren’t undermining the quality of care your ED provides? I’d love to hear your experience. Feel free to comment, send a message or email me directly at cmd@constancedonovan.com.

Sources:  
The Atlantic: “The Problem With Satisfied Patients.”

AMA Journal of Ethics: “Patient Satisfaction Reporting and Its Implications for Patient Care.”

2 Non-Opioid Pain Treatments to Try in Your ED

Laughing gas. Acupuncture. Energy healing. Music therapy. These are just a few of the alternative pain treatments being used in emergency departments today to help curb the opioid epidemic.

With the Center for Disease Control’s recent recommendation that primary care providers should try “nonpharmacologic and nonopioid therapies” prior to prescribing narcotic pain relievers to patients, it’s now time for EDs across the country to begin exploring other pain relief options.

For many patients, their first introduction to powerful pain relievers begins in the ED. Medications such as Percocet and Vicodin provide swift and efficient pain relief, but for some, the social, economic and health costs prove too great. Possible dependence and death are just two of the consequences.

So what can emergency departments do to help curb opioid use and dependence? I recently wrote about a few strategies EDs can implement to combat the opioid epidemic. One strategy not mentioned was the use of alternative therapies, which is beginning to catch on as recent news reports and studies highlight their potential efficacy.   

The New York Times recently profiled the emergency department at St. Joseph’s Regional Medical Center in Paterson, NJ, which is ahead of the curve when it comes to providing alternative therapies for patients presenting with chronic or acute pain.

The story highlights St. Joe’s use of a variety of alternative pain relief techniques, such as nitrous oxide and non-opioid analgesics, to reduce its reliance on opioids, while still providing effective pain relief to its patients.  

“In five months, the hospital has reduced opioid use in the emergency department by 38 percent. St. Joe’s has treated about 500 acute pain patients with non-opioid protocols. About three-quarters of the efforts were successful.” — The New York Times

Success like that warrants deeper investigation so let’s look at two alternative therapies St. Joe’s, and other EDs in the U.S., are using to provide quality care and pain relief to its patients.

1. Nitrous Oxide

Nitrous oxide, better known as laughing gas, has a long history of delivering safe, non-addictive pain relief. As described by the Times, it’s “short-acting, mildly sedating, noninvasive and has countless applications in the ER.” There are few things that can put a smile on a patient’s face while they have a dislocated joint manipulated back into place.  

In a report published in the Emergency Medicine Journal nearly 15 years ago, nitrous oxide is described as having all the characteristics of an “ideal analgesic agent.” It’ safe, predictable, non-invasive, free from side effects and simple to use with rapid onset and offset.

And here are a few instances, according to this report, where nitrous oxide may prove effective:

•      Relief of pain from musculoskeletal injuries
•      Reduction of joint dislocations
•      Adjunct to other analgesia in forearm fracture manipulation
•      Adjunct to lignocaine (lidocaine) in laceration repair
•      Adjunct to other analgesia in wound care and abscess drainage
•      Myocardial chest pain
•      Migraine

So why are we now just rediscovering the benefits of nitrous oxide for treatment of pain? As this 2002 report notes, newer approaches were threatening its use. One can only think, those “newer approaches” were being delivered in the form of opioids.  

2. Acupuncture

Like nitrous oxide, the use of acupuncture within the ED setting is proving to be an effective alternative to opioid pain relievers.

Take the emergency department at Abbott Northwestern Hospital in Minneapolis, Minn. as an example. Two years ago, it was the first ED in the country to have an acupuncturist on staff, and in March of this year the Star Tribune reported “that pain scores in those who received acupuncture alone dropped by the same amount as those who also received analgesic painkillers.”

While studies regarding the effectiveness of acupuncture as a pain reliever are inconclusive, it does “show promise” in alleviating pain among patients in the ED and may be a safe alternative to opioids. Researchers, the Star Tribune reports, hope to prove conclusively that acupuncture relieves pain, reduces costs and should be covered by insurers.

Nitrous oxide and acupuncture are just two alternatives to being used by emergency departments today to limit opioid use and dependence. The results and stories of success are promising, but it will take more than just a simple adoption of these strategies to curb the opioid epidemic. As the stories from St. Joseph’s and Abbott show, emergency departments, and the healthcare industry as a whole, will have to transform the culture of care and pain management to reduce the reliance on opioids.

If you’re interested in learning more about the role emergency departments can play in fighting the opioid epidemic, don’t hesitate to drop me a line. You can also visit the Donovan + Partners website to learn more about the services we offer.

Sources:
Centers for Disease Control and Prevention: “CDC Guideline for Prescribing Opioids for Chronic Pain | Guideline Information for Providers.”

The New York Times: “An E.R. Kicks the Habit of Opioids for Pain.”

American Academy of Pain Medicine: “Acceptability, Adaptation, and Clinical Outcomes of Acupuncture Provided in the Emergency Department: A Retrospective Pilot Study.”

The Star Tribune: “Abbott pioneers acupuncture in the ER.”

Emphasize Teamwork and Communication to Increase Patient Safety

The potential for risk is great in emergency departments. In the hospital setting, EDs rank as high-risk as intensive care units and operating rooms. In all three of those settings, staff members have to work together and communicate clearly to ensure patient safety.

EDs that place a strong emphasis on teamwork, and have in place an effective communication strategy, are able to counteract the inherent risk associated with a patient’s visit to the ED.

Previous studies in health care settings indicate that upwards of 80 percent of medical errors are related to “interpersonal interaction issues,” or more simply, miscommunication. By placing a focus on teamwork and effective communication, an ED will increase not just patient safety, but patient satisfaction, quality of care and staff morale.

Check out these three ways to improve communication and increase teamwork within the emergency department:

1. Implement an Open Door Policy

Effective leaders flatten the hierarchy, create familiarity and make it feel safe to speak up and participate.  — M. Leonard, S. Graham and D. Bonacum

Within EDs, it’s crucial that staff feel comfortable bringing concerns and ideas to their immediate supervisors and those in charge. A sense of strict hierarchy and power structure can discourage your staff from speaking up, but open door policies can counteract those effects and improve communication and enhance teamwork among staff.

2. Standardize Practices

The lack of standardised communication and procedures in medicine increases the importance that team members invest in creating a common mental model; otherwise, there is limited ability to predict and monitor what is supposed to happen. — M. Leonard, S. Graham and D. Bonacum

In many EDs, staff members possess varied levels of experience and responsibility, as well as different personalities and beliefs. To improve communication and foster an environment centered on teamwork among such a diverse group, start by standardizing procedures, practices and communication models. By emphasizing structure within those methods of care, ED staff will all be on the same page and know how and when to communicate concerns or other vital information to their colleagues and those in positions of authority.

3. Be Deliberate

Communication failures are the leading cause of inadvertent patient harm. Analysis of 2,455 sentinel events reported to the Joint Commission for Hospital Accreditation revealed that the primary root cause in over 70% was communication failure. Reflecting the seriousness of these occurrences, approximately 75% of these patients died. — M. Leonard, S. Graham and D. Bonacum

As an ED or hospital leader, when you focus on communication and teamwork, in many instances, you will be changing the culture of your ED. Although the correlation that exists between patient safety and effective communication and teamwork is strong — and benefits, such as improved quality of care and increased patient satisfaction will result — a long-term strategy should be used to implement changes because this type of change takes time and dedication. It’s wise to conduct a deep analysis of every new strategy incorporated, since each step of the process has influence on the overall course of action. Be deliberate and create a schedule with the help of your staff to increase effectiveness.

The positive impact on patient safety, quality of care, patient satisfaction and staff morale that result from improved communication is something I’ve witnessed in many of the EDs Donovan and Partners has had the pleasure of working with. If your ED could benefit from improved communication and enhanced teamwork, feel free to get in touch. Contact Donovan & Partners today at cmd@constancedonovan.com or 651-260-9918. I'd be happy to do a personalized assessment of your ED and provide actionable solutions. For more information on the services we offer, visit our website.

SOURCES:
Nursing Economics: “Measuring teamwork and patient safety attitudes of high-risk areas.”

BMJ Quality and Safety: “The human factor: the critical importance of effective teamwork and communication in providing safe care.”

Troubleshoot Triage to Improve Patient Flow

Seven years ago — from December 2008 through February 2009 — approximately 13 percent of patients who visited the emergency department at Hahnemann University Hospital in Philadelphia left without ever being seen. Over a three-month time period, the 31-bed ED had more than 8,800 visits — overcrowding was a significant problem.

The very next year, over the same three-month time frame, Hahnemann’s ED saw almost 800 more patients — close to nine more per day — but the LWBS rate dropped significantly. Even with the increased patient volume, the ED’s LWBS rate decreased by more than three percent. Three months later, the LWBS rate had dropped even lower to six percent.

But how?

In June 2008, Hahnemann’s ED leadership made a commitment to improve patient flow, and soon partnered with the Urgent Matters Learning Network II — a 6-hospital collaborative that worked with one another to improve patient flow and alleviate overcrowding. Through the consortium, they were able to develop a triage process that worked for their specific hospital given its size, staffing structure and urban location. (ED leaders at Hahnemann ultimately decided to implement the ESI 5-level triage system; introduce a policy of bringing patients to an open bed for triage and registration; and dedicate resources, staff and space for patient fast tracking. And it worked.)

For Hahnemann, implementing an improved patient flow process at triage resulted in lower LWBS rates, less overcrowding and increased morale among its staff. Higher patient satisfaction scores soon followed.

A more recent example of what can result when an ED prioritizes patient flow is Florida Hospital Tampa (FHT), an ED that had been experiencing a nearly 40-percent annual spike in patient volume as it suffered from a 21-percent staff turnover rate. And if that wasn’t enough, patients were ranking its doctors in the bottom ninth percentile nationwide.

An analysis by the Healthcare Financial Management Association outlines how FHT was able to develop and implement a flexible patient flow process combining two proven strategies: team triage and immediate bedding. Dubbed Doc1stER, the new patient flow triage strategy produced quick results — after two months FTH was the most improved ED in its 41-hospital system.

No two EDs are the same and strategies to improve patient flow aren’t one-size-fits-all — staffing, location and space are just a few factors that have to be considered. ED leaders wanting to improve patient flow triage need a plan tailored specific to their ED. With a proven record of being able to identify and develop patient flow strategies, Donovan and Partners can help you examine and improve your current triage process, and then help you implement a plan to improve patient flow in your ED. Contact us today at cmd@constancedonovan.com or 651-260-9918. To learn more about the complete set of health care consulting we offer, please visit www.donovanpartners.com.

SOURCES:

Healthcare Financial Management Association: “7 Tips for Improving Emergency Department Patient Flow.”

Hospitals in Pursuit of Excellence: “Improving ED Flow through the UMLN II.”

4 Signs of Staffing Issues In Your Emergency Department

Proper staffing is an important component of emergency department efficiency. EDs that aren’t appropriately staffed may find it difficult to provide the high-quality and timely care patients seek and deserve.

Determining when and how to utilize your staff for maximum efficiency and cost effectiveness can prove challenging. Patient volume fluctuates and the effects can be difficult to predict even when taking historical data and real-time analytics into account. Additionally, the strengths and weaknesses of your staff must be considered when scheduling, as should the possibility of outside events beyond your control. When it comes to staffing, preparation is everything.

But how can ED leaders conclude whether or not their ED is properly staffed in the first place?

When working with EDs, I look at four indicators first to assess if staffing issues are present. These signs can be very telling when it comes to staffing and scheduling, and whether your team is being utilized in the most efficient and cost-effective manner.

1. Patient throughput time

The first place to look to determine whether or not your ED is properly staffed is your patient throughput times. If they are above the national or state averages or are steadily rising from month to month, staffing issues may be the reason why.

Throughput times may increase for a variety of reasons, so it’s important to analyze other factors to determine which ones may be contributing to the rise. An increase could be related to an inefficient patient flow process; poor communication among staff and other departments; or a combination of factors that should be addressed with a tailored action plan. 

2. Leaving without out being seen (LWBS) rate 

Just like high patient throughput times, increased LWBS rates are a key indicator that your ED isn’t properly staff. Patients will leave if their concerns aren’t addressed in a timely manner. How your ED is staffed — specifically at triage — plays a crucial role in making sure all patients are seen. 

3. Patient satisfaction

If patient satisfaction scores are lower than expected, your schedule may be the reason why. While patient satisfaction scores aren’t the most telling of indicators when it comes to staffing issues your ED may be facing, they are important to consider. Communication and pain management are key drivers of patient satisfaction. However, staffing may be an underlying cause behind these and other issues leaving your patients unsatisfied. If the staff is in a pinch for time, it can take longer for them to get patients the pain management solutions they need in a timely manner. And, a harried staff can make clear, empathetic communication challenging. 

4. Staff morale

ED staff members are under a considerable amount of stress even when an ED is appropriately staffed. If you notice that your turnover rate is on the rise or that there is a general sense of dissatisfaction among your staff, take a look at your schedule. Morale is closely related to the three indicators discussed above — patient satisfaction especially. If patients aren’t satisfied, your staff won’t be either. A solution may lie in a few tweaks to the staff schedule.

The most effective way to properly staff an ED is by first analyzing the strengths and weaknesses of your staff members and creating the schedule accordingly. Although, the natural inclination for many ED leaders facing issues related to staffing is to increase the number of staff on duty and on-call during a given shift. However, this strategy can be expensive and it doesn’t always address underlying issues like playing the right staff in the right positions. 

If you believe your ED isn’t properly staffed, Donovan & Partners can assess the reasons why and create an action plan that maximizes efficiency while keeping your bottom line in mind. Contact Donovan & Partners today at cmd@constancedonovan.com or 651-260-9918. I'd be happy to do a personalized assessment of your ED and provide actionable solutions. For more information on the services we offer, visit our website.

SOURCE:
Collins, Martha: “Staffing an ED Appropriately and Efficiently.”

2 Top Reasons EDs Are Overcrowded

Overcrowding is the most pressing issue facing emergency departments (EDs) today. When an ED is at — or over — capacity, quality of care, patient safety and staff morale all begin to suffer.

There are many reasons why EDs experience overcrowding. While this blog focuses on two of the biggest culprits, it’s important to understand that a variety of factors, both internally within the ED and externally in the community, contribute to this growing problem.

Here are two of the most common issues contributing to overcrowding in the ED, and a few suggestions to help EDs tackle the problem head on.

1. Homelessness

A 2002 study conducted by the American Public Health Administration found that more than 40 percent of the homeless respondents it surveyed had visited an ED at least once over the course of a year. (Nearly eight percent visited on three or more separate occasions.) Fast forward 10 years and not much has changed. This study from 2013 found that single homeless women visited the ED 13 times more often than women in the general population. For single homeless men, the rate was nine times higher than the general population.

While homeless individuals make up a small fraction of the overall population in the U.S., the frequency of ED use by the homeless takes it toll when it comes to crowding.

What can EDs do? First, they must ensure that they have a strong patient flowprocess in place. Optimized patient flow is the first step to eliminating overcrowding, regardless of the cause.

Second, it’s important to build relationships with organizations within the community that can offer assistance to homeless patients once they’re discharged. Make sure you have a list of shelters, mental health and substance abuse professionals, food pantries and other related organizations at the ready. Often, the most effective treatment is to empower patients with information on where they can seek assistance.   

2. Substance Abuse, Mental Health and Psychiatric Boarding

Much like homelessness, patients battling mental health and substance abuse issues find themselves in the ED more often than the general population. In 2007,1 in 8 ED visits were made by adults with a mental health or substance abuse problem. The role of the ED is to perform emergency medicine, not provide long-term treatment for those patients suffering from these chronic problems. But in reality, EDs are on the frontline when it comes to treating the effects.

To help patients with mental health or substance abuse problems — and stem their repeated visits to the ED — EDs should serve as a guide to outside resources and organizations that can offer long-term assistance. Just as with homeless patients — many who may be suffering from mental health and substance abuse-related medical issues — the ED best serves as an intermediary.

The boarding, or holding for treatment, of psychiatric patients is another issue contributing to the crowding of EDs. According to Dr. Scott Zeller, chief of Psychiatric Emergency Services for the Alameda Health System in Oakland, California, ED staff spend twice as much time trying to find in-patient beds for psychiatric patients than they do other patients.

Dr. Zeller says, “Often these patients are kept with a sitter, or in ‘holding rooms’ or hallways on a gurney, some languishing for hours in physical restraints, often with no concurrent active treatment.”

As a solution, he recommends regional dedicated emergency psychiatric facilities that are EMTALA compliant. Patients could go to these centers on their own to seek care, be taken by ambulance when mental health is a concern or transferred there from hospitals that don’t offer psychiatric care once medically stabilized. They could be treated right away rather than spend hours waiting in an ED bed.

Zeller’s suggestion is that the problem should be treated at the source — when patients first present, rather than at the destination — once admitted to the hospital after hours of waiting, boarded in an ED. He sites that a great majority of psychiatric emergencies can be stabilized in less than 24 hours. In his model study, patient boarding times decreased significantly — by more than eight hours, an 80 percent improvement.

How to Solve Overcrowding in Your ED
These two factors which contribute to ED overcrowding have distinct characteristics that call for customized solutions. There’s not a single, universal course of action EDs can take to address overcrowding. Only by stepping back and taking into account all the factors at play, can EDs begin to tailor a specific plan of action.

If your ED is facing issues related to overcrowding, Donovan and Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing and patient flow, along with external issues facing your community, and then help you implement the best solutions to alleviate crowding. Contact us today at cmd@constancedonovan.com or 651-260-9918. For more information on the services we offer, visit our website.

SOURCES:
American Public Health Association: “Emergency Department Use Among the Homeless and Marginally Housed: Results From a Community-Based Study.”

Science Daily: “Homeless people more frequent users of ED, other health services.”

Medscape Medical News: “Mental Disorders, Substance Abuse Linked to Increased Emergency Department Visits.”

Zeller, Scott: “Psychiatric Patient Boarding Problems in the Emergency Department.”

How Real-Time Analytics Will Revolutionize Patient Flow in Emergency Departments

A new and important tool has emerged to greatly improve patient flow in the emergency department (ED) — real-time analytics. By analyzing real-time data to predict potential surges in patient volume, EDs are able to take a proactive approach to optimizing flow. As a result, EDs are able to quickly alleviate crowding and improve the overall quality of care patients receive.

Brent Newhouse, co-founder and head of customer success at analyticsMD, is helping hospitals across the country streamline operations by leveraging real-time analytics. The use of analytics in hospitals is growing, he says, and the results are very promising.

How it Works

Most hospitals live in a reactive world and aren’t using real-time data and computer-driven models. To many the idea may sound futuristic, a little mysterious, a little like Moneyball. But without predictive and prescriptive analytics, hospitals can react, at best, only after an issue has presented itself. Even worse, ED leaders may not know a problem existed until weeks later, after the monthly report is generated, says Newhouse.

In the world of real-time data, predictive and prescriptive analytics can help shape the choices ED leaders make to improve patient flow in real-time. Those working in the ED can follow all this data on a dashboard setup on a computer.

How to Ensure Positive Outcomes

Being able to predict and anticipate a problem is the first step. Taking action based on that prediction is the only way to ensure a positive outcome. With real-time, data-driven models, ED staff are now able to know exactly when patients arrive; how many are waiting and for how long; and where their patients are in the treatment process at the glance of a dashboard.

What’s the Difference Between Predictive and Prescriptive Analytics?

Predictive analytics approximates when a potential surge in patients may be expected based on incoming data; while prescriptive analytics uses this data to provide a recommended course of action, explains Newhouse.

Predictive programs, such as those offered by analyticsMD, are able to determine when patient surges will take place — something that is harder for someone who wasn’t a quantitative math or statistics major to figure out in a moment’s notice. What a huge benefit considering that when EDs become overcrowded, it’s often too late to do something about it. The use of real-time analytics allows EDs to nip problems in the bud and better anticipate and avoid bottlenecks related to surges in patient volume.

For the prescriptive part, these programs can also recommend generally what actions can be taken to alleviate or avoid the issue altogether, which decision-makers can then take into account when making the final decision.

However, in my experience in managing EDs, I should note that, as a rule, prescriptive analytics is not as fully of a developed technology as predictive analytics is at this time. It is just harder for a computer to make some of the judgment calls that an experienced human can. So it’s good to remember that these programs are not meant to replace human decision makers — the experienced health professionals all EDs depend on. Rather they are intended to be tools that vastly improve the information decision-makers have at their fingertips. It can help folks on the ground so they can make wise decisions more quickly — saving time and improving quality of care. That, in turn, makes for happier patients and maximized reimbursements.  

Real-Time Tracking of Resources

Another benefit data analytics can offer your ED is resource management info. If there are certain resources within an ED that are being underutilized, data programs can identify those resources, so decision-makers can put them back into rotation. Empty rooms provide a good example. Real-time analytics can show which room is empty, how long it’s been empty for, and make a recommendation about which waiting patient might make the most sense to treat in it.

The Future of Real-Time Analytics in Healthcare

With this much power, the use of real-time analytics is sure to gain wider prevalence as hospital leaders catch on to its benefits. Currently, it’s proving most helpful in providing hospital staff with information to help optimize patient flow processes, providing quick, high-impact results. In time, the use of real-time analytics will likely begin to influence decisions within other areas of patient care. For now, think of it as a tool that can be leveraged along with other strategies to optimize operations in your ED.

Meshing Data and People

I briefly touched on this important point earlier — collecting all of this beautiful data and then implementing change based on it are two different steps. But you don’t have to take just my word for it. As Venkat Mocherla, director of business development & marketing at analyticsMD mentioned in a recent blog, “ … to get the most out of big data, you need to be able to work with the people on the ground to bring informed change to life.”

Mocherla was inspired in part by Randy Bean in recent Harvard Business Review blog called, “Just Using Big Data Isn’t Enough Anymore.”

“The vast majority of the challenges companies struggle as they operationalize Big Data are related to people, not technology: issues like organizational alignment, business process and adoption, and change management. Companies must take the long view and recognize that businesses cannot successfully adopt Big Data without cultural change,” says Bean.

Keeping this in mind, if you are investing in big data, I advise that it is worthwhile to also invest in getting a plan together for implementing change based on your learnings. This is because I have seen this challenge crop up at hospitals I’ve worked with in the past.  

If your organization is working to leverage big data to improve operations, I’d love to help. I’ve helped more than one ED create actionable steps and coached staff through the process. I can leverage my 20-plus years of experience to help you optimize patient flow and show you how doing that can lead to increased quality of care and patient satisfaction. Drop me a line at

Even if it isn’t an opportunity for us to work together this important step of creating and implementing an action plan is not one to be missed. You want to maximize the investment you’ve made in data collection. It’s just smart business.

And if you’d like to learn more about how real-time analytics can give your decision makers on the ground information that has the potential to improve patient flow within your ED, visit analyticsMD.com.

3 Strategies to Improve Emergency Department Communication

A single breakdown in communication within your emergency department can mean dire outcomes for patients. Consistent breakdowns may even lead to a significant decrease in staff satisfaction, patient satisfaction and overall quality of care.

The way in which information is relayed between staff, patients and caregivers is one of the most important aspects of the treatment process — one that should always be scrutinized and improved upon. By placing an emphasis on effective communication, EDs can expect better and safer quality of care, more satisfied staff, and increased patient satisfaction scores.

Here are three strategies to help improve communication within your ED.

1. Huddle Up

Many EDs experience communication breakdowns during shift changes. Short team meetings before the start of a shift are a great way to promote teamwork and make sure everyone coming on is on the same page at the start of the shift. And if time and circumstances allow, organize another less formal “spot” meeting mid-shift to tackle any foreseeable concerns.

A 2009 Stanford study found short, pre-shift staff huddles were instrumental in fostering teamwork and communication within the ED. Researchers concluded that the positive perception of and “compliance with collaborative decision making” increased after implementing huddles, and, in all likelihood, would lead to higher levels of staff satisfaction and better patient outcomes.

2. Know When Not to Embrace Technology

The ways in which we communicate with one another is ever-changing. New technologies emerge only to be replaced by something different soon after. It’s often tempting to become an early adopter of tech, believing it holds the solution to your problem.

However, the ED isn’t usually the best setting to try untested, new technologies — there’s too much at stake. Here’s a great example:

In 2012, a panel of healthcare providers came together at George Washington University to discuss the role of technology in the ED, highlighting several instances where the implementation of new technology provided no benefit to the provider or the patient. One provider noted how using computers instead of white boards led to a breakdown in communication among staff.  

Swapping a white board for a computer, in some cases, meant losing valuable communication tools used among ED nurses and technicians that seemed negligible to the outsiders who transitioned the data.

The old adage, “if it ain’t broke, don’t fix it,” definitely applies here. Maybe that’s why we’re one of the only professions left using pagers.

3. Identify the Barriers to Effective Communication

When do communication breakdowns occur? And where along the treatment process do they occur? In order to be able to improve communication within the ED, identifying the problem areas is the first step you need to take. Only by identifying the barriers to effective communication will you be able to implement a targeted plan to overcome those obstacles.

Also, it’s important to remember that effective communication strategies should be employed hospital-wide. Some of the most effective communication strategies are born out of EDs. That’s because stress and burnout can flourish in the ED and poor communication fuels it. Good communication is a must to keep those at bay and be able to operate effectively. Communications techniques that do well in the ED have been battle-tested.

If you can employ effective communications strategies within your ED, you can serve as a model for other departments, improving communication throughout the hospital, and maybe even system-wide.

Bottom line: when you are aware of the obstacles present within your ED that are inhibiting effective communication, you’ll be able to develop a course of action for your overall communication strategy that will benefit your ED and hospital patients, staff and budget.

If you could use a hand to pinpoint the barriers to effective communication within your ED, or need assistance implementing strategies to improve communication, don’t hesitate to drop me a line. Contact Donovan & Partners today atcmd@constancedonovan.com or 651-260-9918. I'd be happy to do a personalized assessment of your ED and provide actionable solutions. For more information on the services we offer, visit our website.

Sources:
Heather Tilson, RN, BSN & Angela Vega, RN, MSN, CNL, CRNI & Garrett K. Chan, APRN, PhD, FPCN, FAEN: “Improving Teamwork and Communication in the Emergency Department.”

George Washington School of Medicine & Health Sciences: “Technology in the Emergency Department.”

3 Ways to Lower LWBS Rates in the ED

There can be profound consequences for patients, emergency departments and the healthcare industry as a whole when patients leave an ED before they receive treatment. For patients, delayed treatment can mean sustained illness, pain and even death. For hospitals, high rates of patients leaving without being seen (LWBS) signify a loss of revenue. And for the healthcare industry, when patients seek treatment but don’t receive it, questions regarding appropriate access to care arise.   

The rate at which patients will leave an ED without being seen varies sharply from one hospital to another. In one report published in 2011, researchers looked at patient-visit data from 262 hospitals and found LWBS rates as low as .1 percent and as high as 20.3 percent — a tremendous variation. (The median rate was 2.6 percent.)

The reasons why one hospital may see upwards of one fifth of their patients leave without receiving treatment while another is able to treat almost all of the patients that enter its doors is just as varied. These same researchers offer a few explanations as to why there may be high walkout rates:

• Hospital restructuring and market factors, including the increased number of EDs that have closed their doors.
• The possibility that hospitals in lower-income areas may be closing at a higher rate, causing more vulnerable populations to have less access to care.
• Increased wait times and ED crowding.

It’s important to mention that this study noted hospitals that served a high proportion of low-income and poorly insured patients had disproportionately higher LWBS rates. (Researchers found that the odds of a patient leaving without being seen fell by a factor of .86 for each $10,000 increase in household income.)

With this in mind, what can a hospital do to lower LWBS rates within its ED?

To lower LWBS rates, ED leadership must first identify the reasons why LWBS rates are increasing. Is it because of overcrowding or inefficient patient flow? Did a nearby ED recently close and now you’re seeing an influx of patients? Is your ED properly staffed? Once you identify the causes then you can tailor a plan of action.

Here are a three examples of what EDs have done to curb rising LWBS rates:  

1. Triage is a process, not a location.

In 2011, Illinois’ Elmhurst Hospital moved to a new campus four miles west of its former location. As a result, nearby Gottlieb Memorial Hospital in Melrose Park became the closest hospital for many patients and ambulances in the area. Naturally, due to Elmhurst’s move Gottlieb experienced a surge in average monthly volume — from 1,800 to 2,100 patients — and with that, a 10 percent LWBS rate.

To combat such a high LWBS rate, hospital leaders at Gottlieb implemented a “pull till full model,” redefining triage as a process rather than a location. Nurses were instructed to immediately lead patients to empty rooms and conduct the triage process at bedside. Six months later, Gottlieb’s LWBS rate plummeted to just below four percent thanks to the strategy and other sound initiatives, such as the evaluation of staffing patterns among its nurses and physicians.

2. Communicate with other departments.

In 1999, the ED at Miami Children’s Hospital had a LWBS rate of 5 percent. Its average throughput time was 3.5 hours and patient satisfaction scores were dismal. Over the course of four years, through a series of innovative changes implemented by ED leadership, the ED’s LWBS rate dropped to 1 percent with a nearly one-hour decrease in average throughput time. (Its patient satisfaction scores went from being in the 35th percentile to the 90th percentile.)

How did they do it?

One way was by working with staff from radiology, laboratory, registration and administration to expand capacity and improve flow. By communicating with other departments the ED was able to identify extra space adjacent to their ED to expand into, and then brought on additional physicians and nurses.

They also streamlined the registration process by taking basic information during triage, and pressed hospital leadership to start discharging in-patients in the morning, as opposed to the afternoon. Additionally, housekeeping was requested to clean rooms in a timelier manner.  

3. Keep it simple.

In 2001, Annie T. Sadosty, MD, an attending physician in the department of emergency medicine at Mayo Clinic, and assistant professor at Mayo Medical School, studied the reasons patients leave an ED without being seen. During her research, Sadosty and her colleagues were also able to glean what would cause patients to wait. The results were interesting.

She found that patients would be more likely to wait if they were offered immediate treatment for minor ailments, such as Tylenol for a headache, or ice packs and temporary bandages for injuries. Sadosty also found that by simplyannouncing wait times, patients said they would be more willing to stick around. Providing entertainment for children — think coloring books and toys — would also help, patients told Sadosty.

As you can see, the factors that lead to high LWBS rates are just as varied as the solutions. If you find that your patients are leaving without being seen, Donovan and Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing and patient flow, and then help you implement the best solutions to lower your LWBS rate. Contact us today at cmd@constancedonovan.com or 651-260-9918. For more information on the services we offer, visit our website.

SOURCES:

Renee Y. Hsia, MD, MSc, Steven M. Asch, MD, MPH, Robert E. Weiss, PhD, David Zingmond, MD, PhD, Li-Jung Liang, PhD, Weijuan Han, MS, Heather McCreath, PhD, and Benjamin C. Sun, MD, MPP: “Hospital Determinants of Emergency Department Left Without Being Seen Rates”

GMH ED Staff, Sylwia Wright, RN, MSN, Mark Cichon, DO: “Decreasing Left Without Being Seen”

Urgent Matters: “Reducing the Left Without Being Seen (LWBS) Rate and Throughput Time Miami Children’s Hospital”

Arendt KW, Sadosty AT, Weaver AL, Brent CR, Boie ET: “The left-without-being-seen patients: what would keep them from leaving?”

AHC Media: “Want to drastically cut LWBS numbers? Try ice packs and adding a fast track”

4 More Things EDs Can Do to Combat the Opioid Epidemic

In 2011, more than 420,000 visits to the emergency department were due to the “misuse or abuse of narcotic pain relievers,” specifically opioids, cites the Centers for Disease Control. If we break those numbers down even further, we see that nearly 1,200 emergency (ED) visits per day could have been potentially be prevented if the opioid epidemic currently gripping the country had been addressed sooner.

Last week, I highlighted a series of tactics for fighting the opioid epidemic that Rachael Gordon, BSN, RN and her colleagues implemented at an Oregon ED to stem the tide in their area. This week we’ll look at four more strategies EDs can integrate into their treatment processes to help combat the opioid epidemic in their communities.

1. Connect with resources outside the ED.

When it comes to opioid dependence, it’s important for ED staff to be familiar with all the possible treatment and care options for patients available in their community. Organize a meeting with local addiction counselors and centers, and get to know the Suboxone providers in the community. Effective treatment for your patients may only be a phone call away. Once you know about these options, doctors can “prescribe” a follow-up with these partners rather than a refill on pills.

2. Encourage staff to read Dreamland: The True Tale of America’s Opiate Epidemic.

This book by Sam Quinones paints in detail the grim realities associated with the opioid epidemic. To treat this crisis, health care providers must understand the crisis. This book opens a window into the epidemic.

3. Organize an opioid prescribers’ group.

These groups are a valuable tool in the battle against opioid dependence. Sometimes it just takes a few people who really care to come together to affect change. So reach out to other stakeholders in the community — primary care physicians, prehospital providers, counselors, teachers, local government officials, you name it — and create an ongoing community forum to share experiences and design effective action plans.

It’s not just EDs and healthcare providers that are on the frontlines of this crisis, it is schools, teachers, politicians, store owners, and ordinary citizens that all have a stake in the fight.

4. Stay informed.

It’s important to stay up to date on news and statistics surrounding the opioid epidemic. This epidemic is relatively new in the world of scholarly research and studies are just now being released about the effects, consequences and possible solutions that can be implemented in response. In order to stop the opioid epidemic in its tracks, healthcare providers have to stay on top of the latest findings related this growing problem.

In conclusion, we all have to work together to combat the epidemic and do our part to not make matters worse. It’s easy to point fingers as to the cause of this crisis, but placing blame won’t solve this problem — we’re all stakeholders in this battle. Just like working with individual patients in the ED, treatment of this epidemic will require teamwork, clear communication and confidence that the work we do will lead to positive outcomes.

If you’re interested in learning more about the role emergency departments can play in fighting the opioid epidemic, don’t hesitate to drop me a line.

SOURCES:
Centers for Disease Control and Prevention: “CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.”
Rachael Gordon, BSN, RN, Natividad Medical Center in Salinas, Calif.

The Opioid Epidemic: 4 Things EDs Can Do to Combat It

Emergency departments have been, and always will be, on the front lines of pain relief. If a patient arrives at triage suffering from chronic or acute pain, it’s the responsibility of the emergency department (ED) and its staff to do all they can to alleviate that pain and strive to provide patient satisfaction.

Now, as over 40 percent of ED visits in the United States are in response to pain, and as an opioid epidemic plagues communities across the nation and is making headlines, EDs have to be extra vigilant when it comes to managing that pain.

Rachael Gordon, BSN, RN an emergency nurse at Natividad Medical Center in Salinas, Calif. knows firsthand the difficulties EDs face when it comes to battling the opioid epidemic. Gordon previously worked at an ED in Oregon, where she was instrumental in implementing a program in response to the rising rates of opioid dependence.

This week we’ll look at four tactics EDs can integrate into their treatment processes that will help staff address many issues stemming from the opioid epidemic. These strategies, based on Gordon’s experience in Oregon, have far-reaching potential for EDs everywhere in the country.

1. Don’t discharge patients with more than three days’ supply of opioids.

Emergency department staff are not responsible for the long-term management of patients’ pain. It is important to acknowledge that patients may have difficulty making an appointment with their primary care physician (PCP) — or, in some cases, may not even have a PCP — but prescribing more painkillers than is absolutely necessary increases the likelihood a patient will develop a dependency on the drugs.

2. Do not fill.

In some instances, specifically for persistent, non-cancer pain patients, ED staff must make the difficult decision of not prescribing a narcotic painkiller. Though patients may continue to experience discomfort, there are a variety of alternatives ED staff can offer, such as hydrazine, clonidine and Zofran, that patients can take until they are able to see their PCP.

3. Check your state’s PDMP and train staff on how to properly utilize it.

Prescription Drug Monitoring Programs are an important tool when it comes to identifying patients who may be at high risk of developing an opioid dependency. These state-run databases allow providers to access the prescription drug history of a patient and provide the critical information necessary to determine whether or not the patient would benefit from an early intervention.

4. Be compassionate.

If patients are exhibiting signs of a prescription drug dependency act with compassion. Just like their pain, their dependency is a chronic condition — one ultimately created by healthcare providers and one that has, unfortunately, yet to be addressed. These patients need continued care, and many times the first step to treatment and overcoming a dependency begins within the ED.

Next week, we’ll explore four more steps EDs can take to address the challenges brought forth by the opioid epidemic. In the meantime, if you’re interested in learning more about what strategies EDs can implement to battle this crisis, feel free to drop me a line.

Sources:
American College of Emergency Physicians: “Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department (June 2012).”

Rachael Gordon, BSN, RN  an emergency nurse at Natividad Medical Center in Salinas, Calif.

The 2 Greatest Threats to Patient Safety in the ED

Emergency departments face several threats when it comes to patient safety and quality but the top two are overcrowding and a shortage of on-call specialists, according to the American College of Emergency Physicians (ACEP).

Cut the Crowds: It is Not Always a Staffing Shortage Issue

Overcrowding is a well-known problem — there are news reports every week about how EDs are short on beds, and how patients are unable to receive the treatment they need because of it. Hospitals often tackle the problem with multi-million dollar expansions, ambulance diversions or by bringing on additional staff. Sometimes these solutions work; many times they don’t.

As health care professionals we know treating a patient’s symptoms only provides temporary relief. For example, it’s not the recurring headache that’s the problem; it’s what causes these headaches that we need to be concerned with. We have to do the same type of digging to diagnose a troubled ED.

To remedy overcrowding we have to look at it as a symptom with a wide variety of potential root causes, none of which are necessarily universal. Just because one ED is overcrowded because of “boarding” — which ACEP suggests is the primary cause — doesn’t mean that another ED facing a shortage of beds is having trouble for the same reason.

Look Beyond Boarding Issues

While boarding may be the predominate cause of overcrowding for a vast number of EDs, it too, is just a symptom of even more underlying problems. Maybe the ED across town closed recently, or your area is in the grasps of an opioid epidemic. Overcrowding could be a result of inefficient staffing in the ED, or inopportune scheduling of in-patient surgery in the hospital itself. When it comes to overcrowding there are a wide variety of causes — and combination of causes — that could be at the root. And in order to remedy it, a dynamic and tailored plan of action has to be implemented.  

What’s Causing the Specialist Shortage?

This same idea holds true for the shortage of on-call specialists. At the root of this shortage of neurologists, trauma and orthopedic surgeons, and the like, isn’t that there’s an actual decrease in the number of specialists able to treat patients. It’s because these specialists are often opting out of on-call responsibilities, typically mandated by EMTALA, by leaving the hospital setting. So the solution isn’t more specialists — it’s encouraging the ones we already have on staff to stay.

Again, the shortage of on-call specialists is a symptom of deeper issues. Specialists aren’t leaving the hospital setting because they don’t care about these patients or don’t want to treat them. According to ACEP, it’s typically because:

• they believe there’s an increased liability that exists when working in the ED;
• or that they think on-call pay is inadequate;
• or because of the quality of life concerns that stem from being on call.

Be a Detective — Dig!

When it comes to these two threats to patient safety and quality, we have to remove our blinders. It takes a broad view with many sets of eyes to identify the real issues that inhibit our ability to deliver the safe and quality care our patients deserve. Threats like overcrowding and a lack of on-call specialists are obvious, but in many instances, the roots of the problems remain buried. In order to solve these problems, we have to dig them up.

If you need help getting to the bottom of challenges in your ED, drop me a line. I’d be honored to chat about how I might be of help. And, for a broad look at the services my consulting agency provides, check out our website:http://donovanpartners.com/

Sources:
American College of Emergency Physicians: “Patient Safety and Quality of Emergency Care.”
American College of Emergency Physicians: “Study: Shortage of On-Call Specialists Spreads Nationally Could 'cripple' emergency, trauma care.”
Nathan R. Hoot, PhD, and Dominik Aronsky, MD, PhD: “Systematic Review of Emergency Department Crowding: Causes, Effects, and Solutions.

3 Important Characteristics of Emergency Department Nurses and Why We Love Them

It’s easy to take emergency department nurses for granted. Even though they’re what I consider the eyes and ears of any busy ED, they don’t always receive the credit and appreciation they deserve.

Friday marked the beginning of National Nurses Week, reminding us to honor and celebrate these nurses who are so instrumental in providing safe, quality care in the ED. But what makes nurses so amazing? Here are just a few reasons to salute these hardworking women and men who are vital to a successful ED..

Uncommon Agility

You would be hard pressed to find any other profession where agility is so crucial to success. Being agile in an ED means always being on your toes, anticipating the needs of patients, their families and doctors. Agile nurses know what a patient or doctor needs before they themselves know they need it and the right questions to ask. Nurses in many ways have the keen ability to see in the future, which is vital when a life is on the line.

Superb Communication Skills

Anticipating the needs of patients, family members and doctors is one thing — being able to communicate with each of these very distinct groups is another.

First and foremost, great nurses are incredible listeners. They absorb directives from doctors that could easily be drowned out by the bustle of a busy ED. They also connect with patients and caregivers, listening to them in a way that help give the patient a voice in their care.

But listening is only half of communication. Nurses also have to speak with patients in a clear, concise way that’s easy to understand. One minute they may be talking to a 6-year-old boy with a broken arm, and the next, a 50-year-old man with an addiction to prescription painkillers. I can’t think of another profession where one communicates with so many different types of people, across so many demographics and socio-economic groups.

Enduring Empathy

Nurses care about the wellbeing of their patients — though they hope they never see them again, in the ED at least.

Empathy is the reason nurses are able to be considerate and sensitive when setting expectations regarding recovery. Empathy is also the reason why nurses return to work after a hard shift.

The strong sense of empathy that runs through each and every emergency department nurse isn’t always obvious, but we can rest assured it’s there — empathy is the reason nurses show up to work each and every day.

If the emergency department is the front door of a hospital, ED nurses are the ones making the very first impression and make sure that door is open to those who need it most.

One week really isn’t enough time to honor nurses and the important work they do, but National Nurses Week is a nice reminder for hospital leaders, doctors, patients and their families to show their appreciation for everything nurses do.

To learn more about what my company Donovan + Partners does, please check out our new website www.donovanpartners.com.

Wait Times: How Does Your ED stack up?

Many patients might look at the emergency department (ED) like they would their neighborhood deli — first come, first serve. Luckily, for critically ill patients, this isn’t the case. The patients who need immediate treatment are going to receive it no matter how many patients are waiting.

Explaining this logic to a patient with a broken finger or a parent with a child experiencing cold symptoms may not be easy. The ED is the last place they want to be, and to them, their pain, or child’s pain, is a priority. Patients sometimes aren’t the best judge of their symptoms, and finding a way to get care outside of the ED can prove difficult depending on the day of the week, time of day and where they live.

The stats seem to reflect that. For example, from 2009 to 2010 more than 25 percent of all ED visits by children were for cold symptoms. For adults 12 percent of visits were deemed non-urgent, for cold symptoms and the like.

But it’s not just more non-urgent patients seeking care that are adding to wait times. With increasing numbers of patients visiting the ED for nonurgent conditions, wait times are bound to spike.

Year after year, average emergency department wait times have increased across the nation because visits are too. More people are seeking treatment at EDs — for urgent and nonurgent conditions — while the number of EDs is decreasing. According to the CDC the number of patient visits to EDs increased 32 percent over a 10-year period from 1999 to 2009. And at the same time many EDs closed their doors due to financial constraints.

So how does your ED’s average wait time compare?

One Measure: Broken Bones

The wait time for treatment of a broken bone is an important measure when it comes to hospital wait times. Of course, there’s different types of breaks and the severity of each will vary, but on average in 2014, a patient had to wait 54 minutes before receiving pain medications upon arrival in the ED.

For a national average, 54 minutes is long and depending on where a patient lives and which hospital they choose for treatment, the wait could have been much longer.

Take Washington, D.C. for example. Emergency departments in urban areas typically have longer wait times. In D.C., patients suffering from a broken bone had to wait an average of 69 minutes before receiving pain meds. This is only 15 minutes more than the national average, but with eight hospitals in the area the wait times varied drastically. If a patient sought treatment for a broken bone in D.C., they may have waited as little as 50 minutes for pain meds, or as long as 150 minutes depending on which ED they chose.

Difference in Wait Times Correlated to Patient Demographics

So who is facing longer wait times besides the no-critical patient? It seems adults go last and the old and the young are put first. According to the Centers for Disease Control and Prevention, Older patients, age 65 and older had the lowest mean ED wait time from 2008-2010 at 48 minutes. Children’s was 51 minutes And, adults 18 to 64 tended to have to wait the longest at 58 minutes.

Researchers found a difference when it comes to gender. Females experienced longer waits than males — four minutes more than men (57 minutes and 53 minutes, respectively).

There were even interesting stats around race. Non-Hispanic black patients experienced the longest wait times (68 minutes), while Hispanic patients waited 60 minutes, and non-Hispanic white patients waited 50 minutes.

What Will the Future Hold When it Comes to Wait Times?

On average they’ll increase, but there’s no reason your ED can’t be an outlier. First, you need to know where you stack up, which you can do by checking outProPublica’s ER Wait Watcher.

If you find that your patients are waiting longer than those at a nearby hospital, Donovan and Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing and patient flow, and then help you implement the best solutions to cut wait times. Contact us today at cmd@constancedonovan.com or 651-260-9918.

Sources:
ProPublica: “ER Wait Watcher, Which Emergency Room Will See You Fastest?”

Centers for Disease Control and Prevention: “Wait Time for Treatment in Hospital Emergency Departments: 2009.”

Centers for Disease Control and Prevention: “Health, United States, 2012, With Special Feature on Emergency Care.”

American College of Emergency Physicians: “Emergency Department Wait Times, Crowding and Access Fact Sheet.”

The Importance of a Strong Discharge Checklist

The moment a patient is discharged from the emergency department (ED) should be a moment marked with confidence for both the patient and ED staff. Each party should be satisfied with the care provided and that the chance of a return visit to the ED in the near future are low.

A visit to the ED is typically stressful for a patient and their families. From the time they walk in your door until they get to discharge can be an arduous experience. But by engaging patients with effective communication throughout thier experience and especially before the leave they’ll be empowered with the necessary knowledge to ultimately take control of their care.  

One important tool for effective communication every ED should utilize is the discharge checklist.

According to the Robert Wood Johnson Foundation, patients should have a solid understanding of these six things prior to discharge:

1. Their overall care plan;
2. Where they will be going after discharge;
3. If transferred, who to contact if a problem arises;
4. Medication instructions along with potential side effects;
5. What symptoms to be on the lookout for;
6. And any necessary follow-up appointments.

This is a lot of information for a person or family to absorb, especially when they find themselves in the ED. A strong discharge checklist will provide this essential information in a way that’s easy for patients and caregivers to understand as the ED staff person reviews it with them and once they take it home. Just as important, a strong discharge checklist will instill confidence among the ED staff that all pertinent information has been shared with the patient.

So, what does a strong discharge checklist look like?

The best discharge checklists are educational in nature and address social and medical risk factors that could result in a return visit to the ED. If the patient is homeless, a list of area agencies that offer housing assistance should be included. The same goes for patients who have issues involving substance abuse.

Strong discharge checklists should also be simple in form and created with the demographics of the community the ED serves in mind. If there is a high population of Spanish-language speakers in the community, it’s best to have the checklist available in Spanish as well.

Discharge checklists of course can’t be tailored to every individual patient, but a strong checklist will cover the necessary bases to ensure discharge is successful for the vast majority of patients.

The Robert Wood Johnson Foundation offers a good model for what a strong discharge checklist should look like, as does Medicare.gov. The important element these two checklists share is that they both empower patients and caregivers with points of action.

For example:

I understand what symptoms I need to watch out for and whom to call should I notice them.

This is a good example of how proper wording places the primary responsibility of care on the patient with ED staff acting as a guide. Nurses aren’t checking off the box when they relay necessary information to patients. Instead, patients and caregivers are checking the box off when they have a firm grasp on the information that’s been presented to them.

The discharge process for every ED is different, but the one tool each should be utilizing is a strong discharge checklist. While there’s not a “one-size-fits-all” checklist out there, Donovan and Partners is available to assess your ED and help you develop a tailored discharge checklist to lower return rates and improve the discharge process.  Contact us today at cmd@constancedonovan.com or 651-260-9918.

SOURCES:
Robert Wood Johnson Foundation: “Care About Your Care Discharge Checklist & Care Transition Plan.”

Medicare.gov: "Your Discharge Planning Checklist."

American College of Emergency Physicians: “Improving the ED Discharge Process.”