Emergency Department Bottleneck

looking at mortality rates in patients seeking emergency care conclude that the rate of death is substantially higher during times of crowding (Richardson, 2006, p. 213).

A visit to the emergency department (ED) is usually associated with negative thoughts by most people. It creates preconceived images of overcrowded waiting rooms and routine long waits for treatment (Jarousse, 2011). From 1996 to 2006, ED visits increased annually from 90.3 million to 119.2 million (32% increase). During this same time period, the number of EDs has declined by 186 facilities creating the age old lower supply and greater demand concept (Crane & Noon, 2011). There are many contributing factors that have led to an increase in ED visits. A few of these key drivers include lack of primary care access, rising of the uninsured population, dwindling mental health services, and the growing elderly

When focusing on the Centers for Medicare and Medicaid Systems strategies for improvement with unnecessary emergency room visits, a major key area is accessibility to health care at the appropriate health care setting. For many years, there has been the perception that the emergency department is the only place for someone who is uninsured or underinsured can go to receive the needed and appropriate health care, and in some situations that may be the case. (Rhodes et al, 2013, p.394) Due to the decreases in reimbursements for the publicly funded, more and more physicians are opting out to treating these patients, thus leading to an increase in emergency department utilization. According to a study conducted by Rhodes, Bisgaier, Lawson, Soglen, Krug, and Haitsma, this is becoming a greater concern for the

S (situation): Hi, my name Kelsey and I am a nurse in the emergency department. I am calling about Shannon O’Reilly’s most recent laboratory results.

14 million Canadians visit Emergency Departments (ED) every year, and also reported to having the highest use of EDs (Ontario Hospital Association, 2006). ED overcrowding in Canada has become an epidemic. ED overcrowding has been defined as “a situation in which the demand for emergency services exceeds the ability of an (emergency) department to provide quality care within acceptable time frames” (Ontario Ministry of Health and Long Term Care, 2014). This has been an ongoing problem across Canada. Ontario has developed an initiative to reduce ED wait times by implementing a variety of strategies and collaborating with other institutions. This paper describes the Emergency Room National Ambulatory Intuitive (ERNI), an

Approximately half of a million Americans are homeless, living in shelters or on the streets at any one time (Galea & Vlahov, 2002). The homeless population utilizes the emergency room to gain access to, primary care, nutritional, pharmaceutical and basic needs with non-medical issues is a contributing factor to emergency room overcrowding. The non-medical can primary care component needs to be moved out of the acute care setting of the emergency room but still readily accessible to the homeless clients.

Throughout this course I have learned about the various challenges that impede productivity and efficiency at today’s hospitals. These issues facing the modern healthcare organization come in varying forms from technological, staffing, and financial to name a few. There are no limits to what hospitals can face in these modern technologically savvy times. Below are the major issues that today’s hospitals are facing, though there are many facets to these topics it will be described as best as possible to meet overall challenges:

I would like to give you some insight as to the daily operation of a major Emergency Department in this city. Not unlike many other “ER’s” the nursing staff is tasked with the triage or assessment of patients in order to sort by priority. The nurse is then tasked with maintaining flow of the department and ensuring the timely care and physician evaluation of patients. This requires clinical nursing judgement and expertise which is tested constantly. To explain this plainly, nurses are faced with a meat grinder which cannot stop. There may be twenty patients in the lobby with ambulances lining up. The room nurses are trying to

When overcrowding occurs, patients are placed in the hallway waiting for room to be transferred to. Any time overcrowding occurs most ambulances divert away from the closest hospital to the patients and in this situation hospitals lose a lot of revenue. Data published in the US Department of Health and Human Services (HHS) in 2004 report national hospital ambulatory medical care survey on ED summary depicted that ED in United State are approaching a boiling point in terms of increasing patient demand and shrinking bed capacity, Levin et al (Fall,2006). According to the Institute of Healthcare Improvement, a recent survey conducted by the American College of Emergency physician of about 200 hospital administrators, majority pointed at overcrowding as their major constraint and about 60% said overcrowding in their facility forces the diversion of patients with urgent need

St. Vincent’s Medical Center, a 501 bed facility located in Jacksonville, Florida, provides general medical and surgical care to the North Florida Region. St. Vincent’s admits over 26,000 patients annually. The average occupancy rate is approximately 84% with the Emergency Department (ED) peeking at 100% for approximately 4-12 hours daily. The hospital is struggling with availability of bed space. This shortage of available beds creates a bottleneck in the ED on high census days. Bottlenecks are created in the ED when there is a shortage of inpatient beds to place admitted ED patients. Thus, patient flow, or throughput, is becoming more and more important.

Hospitals need to measure performance in key areas that affect patient flow and capacity, and identify the drivers of capacity constraints and key opportunities for performance improvement.2 “Identifying real drivers of capacity constraints and key opportunities for performance improvement can be achieved by: Monitoring how many cases are being diverted from the hospital, understanding how systems and tools are functioning for patient admission, discharge, and transfer, determining the efficiency of activities such as bed tracking and control, patient transportation, housekeeping, and care delivery.3”

Emergency room overcrowding is a major issue throughout not just the United States but in many countries. There have been many strategies on how to combat this issue as patient satisfaction is often being a major variable on hospitals being reimbursed, which interventions are most helpful? One intervention that is gaining more and more popularity is advertising wait times. Through a PICO search with key words of “ED triage” and “patient satisfaction” or “wait times” provided some great original research over the past five years that has been peer reviewed in the Journal of Canadian Association of Emergency Physicians. While multiple research papers came up, the methodology and potential of taking this particular study further was of great interest.

Due to ineffective management systems, inefficiency is increasing, which often leads to congested emergency rooms, customer complaints, and lost revenue. Over the past seven years, Six Sigma concepts are increasingly being implemented in the healthcare industry. Despite the challenges of adopting these concepts, the healthcare industry uses them to improve services rendered quality, increase efficiency and reduce fatal human errors. Primarily because Six Sigma is based on a comprehensive approach on improving the human and transactional aspects of the process (human performance and task completion). In the case of JPS, the factors that determine quality and efficiency are the flow of information and interaction with the patients. Using the Six Sigma DMAIC process improvement approach, JPS Emergency Department should be able to streamline information flow and achieve strategic business results (p.

A quantitative study conducted by Lifvergren, Gremyr, Hellstrom, Chakhunashvili, and Bergman (2010) analyzed the experiences and from a hospital group during a three-year period after the introduction of Six Sigma. It reports on 22 large Six Sigma improvement projects, their results and influence on other improvement activities. The study shows that 75% of the completed projects reached their goals within 18 months. The average net cost savings per completed project/year was $55,300. Overall, the results showed that Six Sigma is a useful concept when trying to improve healthcare processes. They recommend that Six Sigma should be an addition to the improvement practices used in healthcare development initiatives. It was also observed that the Six Sigma program can create much organizational pull regarding quality management and improvement efforts if teamwork is applied.

Middletown Hospital is a 200-bed, not-for-profit-general hospital that has an emergency department with 20 emergency beds. The emergency department handles on an average 100 patients per day. The hospital’s CEO has authorized the Six Sigma Team (SST) to address complaints received from patients seeking treatment between 6:00 p.m. and 10:00 p.m. The complaints are centered on waiting times and poor service. During this time the data indicates that approximately 70% of the department’s admissions occur (University of Phoenix, 2009, Course Syllabus).