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Tom Sharon
Current model of patient-flow dynamics simply not working


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Emergency Room Waiting Time

There is a relationship between how long patients have to wait to see a physician and the outcome. Injuries and illnesses that need medical and nursing intervention are time sensitive. The longer the wait, the more damage occurs because there is a loss and/or deprivation of basic needs for survival, such as oxygen, blood, electrolytes (potassium, sodium, etc.), sugar, water, immunity, skin integrity, and the like. Additionally, waiting time in the emergency department is determined, in part, by factors such as the ratio of physician and nurse to patient, laboratory turnaround time, x-ray turnaround time, and average length of stay.

These factors are obviously interdependent. Most urban emergency rooms are overwhelmed and overcrowded. For some it is occasional, but for most it is the norm. Health-care planners do not seem to be assessing community needs before pouring the cement. The planners are building the emergency rooms too small, and the number of doctors and nurses are too few to provide safe care for the overwhelming numbers that converge at the door. This is a bizarre phenomenon because it defies logic. It would seem that the faster they move the patients through the system, the more revenue there will be.
 
Upon closer examination, you would find some correctable contributing factors, such as waiting four hours for the results of a ten minute laboratory test, inadequate staffing of nurses and technicians, and/or lack of prompt response from on-call specialists.
 
Additionally, patients who have completed the diagnosis and stabilization process remain in the treatment area waiting for a bed or for transportation. Thus if a patient hangs around for two hours for the ambulance to bring him or her back to the nursing home, the next person then has to wait two hours for that space to become available.
 
Moreover, when such conditions exist with hundreds of people moving around in a frenzy, the state of affairs usually becomes chaotic and confusing. Charts are misplaced, specimens do not get to the laboratory, the doctors cannot find the x-rays, and sometimes the nurses have to go look for their patients. These situations further slow the process.Accordingly, the people who manage the emergency rooms need to develop a new model of patient-flow dynamics because the current design is simply not working.
 
What's more, on the subject of overcrowding in the emergency department, the lack of available beds in the respective intensive care units and/or floor exacerbates the overloading. Hospital managers in many instances are loath to divert incoming patients to other facilities because it translates to a loss of revenue. Frequently, under such management, doctors admit patients and hold them in the emergency department until a bed opens up, which could take days. This deplorable policy has been common practice for the entire twentyseven years that I have been a nurse, and it continues to this day. I have experienced this predicament as both a nurse and a patient. I once stayed at Montefiore Medical Center in 1986 on an emergency room stretcher for two days. It was pure torture. The stretcher was too narrow and too hard. I was lying on a metal platform with a thin foam rubber slab between it and my backside. The resultant pressure was painful. The reason given for this torment was that there were no beds available. The management should have offered me an opportunity to transfer to another hospital in the area, but that was not an available option because the system was not set up for true customer service. Considerations like safety, comfort, and dignity are not a part of the policy-making process.
 
Finally, the emergency room is not equipped to house patients for more than four hours at a time. If waiting for a bed causes the patient to remain longer than that, the quality of care falls below standard. The emergency room nurses cannot reasonably provide for the needs of new arrivals and give the time and attention required for a proper nursing assessment and management of the admitted patient's condition.
 
The solution to the universal emergency department debacle is complex. Certainly, if you have been waiting several hours, you would feel restless, frustrated, and angry. You might even worry that something bad will happen if you do not get to see a doctor in the next few seconds. The situation can get very ugly at this point. Once, an emergency department administrator got an inspiration to bring in a magic show to entertain the people in the waiting room and ease the tension. It had the opposite effect, and the magician had to disappear. Although he was good at his craft, he was playing to the wrong audience. One man told him where to shove his rabbit, and a woman shouted, "Why don't you conjure me up a doctor so that I can get treated for this lousy migraine!" When the performer pulled out his rope trick, another man told him to go hang himself with the rope.
 
But it is important to know that loud complaints are counterproductive. The last thing you need is to cause the nurses and doctors to want to avoid you. Once it becomes apparent that you have waited too long, you need to understand that the triage nurse has decided that the patients going ahead of you would have a higher risk than you of dying without prompt attention. This does not mean you have no risk. This is a comparison of your risk against that of others, and you came out on the bottom. Remember that the triage nurse is simply choosing between two or more people to fill one vacant slot.
 
While being careful not to displace another person who would need medical attention sooner than you might, you can take a few actions that might reduce your waiting time:

  • Ask the triage nurse to give the rationale for your low priority.
  • If you feel your symptoms have gotten worse, report it and say that you feel your condition is deteriorating.
  • If you believe that the decision to make you wait is not correct, call the nursing supervisor..
  • Remain truthful about your symptoms and don't exaggerate..
  • Do not lie on the floor pretending to have passed out. You will not likely be able to fool the nurses and doctors, and if you do, you could get the wrong treatment.

Once you are inside you will likely experience more waiting for blood and urine tests and/or x-rays. This will take another four to six hours. The best way to approach this is to let the charge nurse or supervisor know that you are aware that a lab test takes no more than a few minutes and that an x-ray takes ninety seconds. At this point, you can ask a staff member to call the laboratory or x-ray department to find out what is going on. However, it is important to realize that this situation is not going to improve instantaneously. The most common reason for such delays is simply that the laboratory and x-ray facilities and the personnel are inadequate in meeting demand. Increasing such resources would require an act from top level executives committed to improving emergency services.
 
Furthermore, the hospital administrators have the option of going on diversion. This is simply calling the 911 dispatch office to report that the hospital is over capacity and that ambulances need to divert patients to alternative facilities. There are capacity ordinances in every municipality governing all public places, like theaters, restaurants, and houses of worship. Why do the local governments allow hospital executives to cram in more people than they can safely handle? In this situation it is not a matter of being unsafe in case of fire - it is unsafe as it is. Thus if you find yourself sitting in the emergency waiting room for several hours and the place is jam-packed with people, ask the nursing supervisor if the emergency room has been placed on diversion. If it has not, then ask, "Why not?" I do not know what answer you will get, but it is the question that matters. The question, if repeated often enough by many different people, will make decision makers realize that the public is mistrustful of their management policies.
 
To offer some additional solutions, there are some emergency centers that are managed better than others. It is important to be able to choose one that will give you and your family a better chance for the most effective care possible should you ever need it. You will need to make such a choice as soon as possible, because you would not have time to make a selection during an emergency. You should know where each emergency room is located in your area and the shortest route to get there. It would also be advisable to make an appointment with the emergency department administrator to inquire about the quality of care in his or her emergency room. Here is a list of questions to ask:

  • How many attending doctors are on duty at anyone time and is that number consistent with established policy?
  • How many nurses are on duty during each shift and how many are supposed to be on duty?
  • How many patients can you fit in the treatment areas at any one time?
  • Are the attending physicians board certified in emergency medicine?
  • Do your nurses and doctors have the certification to provide advanced adult and pediatric life support?
  • Do you have a trauma team?
  • May I see your list of specialists on call?
  • If I need a specialist that is not on your list, where will you transfer me and how long will that take?
  • What is your policy on leaving patients in other areas such as the x-ray department?

To begin with, getting answers to the first three questions will enable you to calculate how many people each doctor and nurse can take care of at any moment in time. If the ratio is greater than ten patients for everyone doctor or five patients for everyone nurse, that emergency department is understaffed and unsafe. You should tell the administrator that this is unacceptable. Expressing your concern and encouraging others to do the same begins a process of cumulative feedback that will ultimately have a positive effect.
 
Secondly, aside from making sure that the staff members have the right credentials, the issue of available specialists is a crucial matter. Not every hospital has the ability to handle critical emergencies such as brain hemorrhage or stab and gunshot wounds. You should find out what specialties are available and the usual response time once the emergency attending makes the call. I once triaged a twenty-five-year-old woman who came in looking extremely pale with low blood pressure and abdominal pain. I treated her for shock and called in a request for immediate attention. The emergency attending physician came out, made a fast assessment, and decided that we were dealing with an ectopic pregnancy (the embryo attached itself inside the fallopian tube), which is life-threatening. She called the gynecologist, who got there in five minutes, and the patient was in the operating room within thirty minutes of her arrival and ultimately recovered. In this case, the successful outcome was almost entirely dependent on the prompt response of the specialist.
 
Finally, one of the most common mistakes made in emergency nursing care is leaving patients in areas outside of the emergency department. This happens most frequently in the x-ray department corridor. The patient is either waiting for the x-ray technician or waiting to be brought back to the emergency room. Too often such people experience a potentially life-threatening crisis with no one in attendance, such as a semiconscious sixty-eight-year-old woman who vomited and choked while lying supine on an emergency room stretcher. The nurse decided to leave the patient alone for a few minutes to avoid exposure to the x-rays. Within the time it took to shoot an abdominal film, the woman's stomach contents went into her lungs. The result was extensive brain damage and death two days later. If the nurse had donned a lead apron and remained with the patient while the x-rays were being taken, she could have turned the woman's head to one side and prevented the choking. Thus since such occurrences are unpredictable, there should be a nurse in attendance at all times with patients who have an altered level of consciousness.
 
In summary, the emergency department is a place to which many people owe their lives. When properly run, it is the only safe haven for many hurting and frightened folks. Unfortunately, if you have ever been to one, you know that virtually every emergency room in existence is too small and has too few nurses and doctors to provide timely treatment to all who turn up. It usually looks like there has been a disaster causing massive casualties. There seems to be a universal belief among those who plan and manage that an overcrowded emergency room serves the financial needs of the institution. Otherwise, the spaces would be larger, there would be more staff, and, unless there is a real calamity, waiting time of more than one hour would be astonishing.
 
As you make your rounds to evaluate the safety of the emergency departments in your area, use the comparative tool on the next page.

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