ED management : the monthly update on emergency department management
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To address time and space challenges in the midst of surging demand, the ED at St. Mary Medical Center in Langhorne, PA, turned to the split-flow model, an evidence-based practice that relies heavily on the queuing theory to improve patient throughput. In less than one year, the approach has enabled administrators to reduce door-to-physician times from an average of 47 minutes to 23.5 minutes, and overall length-of-stay in the ED for discharged patients has been slashed by 21 minutes. ⋯ They may then be moved to a holding area while awaiting test results. Patients are constantly moving in the split-flow model, so it is important to pay close attention to handoffs. Patients will begin the process with one nurse and finish with another.
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When monster storm, Hurricane Sandy, struck the northeastern coast in late October, the emergency systems for many hospitals in the region were stressed beyond their limits. At least four hospitals in the region had to be evacuated, and many hospitals lost power and access to essential services. Using backup generators, CentraState Medical Center in Freehold, NJ, was able to keep its doors open throughout the emergency, but the event highlighted a number of vulnerabilities that administrators will work to improve. ⋯ The hospital established care areas next to its emergency department to handle the demand, and it also enabled physicians in the region to see patients in offices on an ambulatory campus, adjacent to the hospital. Emergency department visits increased by about 41% during the hurricane week, admits went up by about 50%, and the number patients sent to observation went up by 450%, according to hospital administrators. In the future, hospital leaders say practice drills need to regularly test for events that cause many systems to go down, rather then testing for one vulnerability at a time.
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The ED at The Aroostook Medical Center (TAMC) in Presque Isle, ME, is a level II trauma center. It is the largest in the region, with only 89 beds. It has undergone a transformation in recent months, with average wait times to see a provider going from four to five hours down to less than five minutes, and the left-without-being-seen (LWBS) rate has been slashed from a high of 7% down to less than 1%. ⋯ Responsibilities for charge nurses have been redesigned so that they have the power to monitor and facilitate patient flow. The ED has initiated more point-of-care testing so that nurses and techs can conduct many routine tests on their own. While the lean model relies on staff-driven solutions, administrators make the difference when it comes to sustaining changes and minimizing employee resistance.
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Several new studies presented at ACEP's scientific meeting in October poke holes in the conventional wisdom that frequent ED users are abusing the ED for routine health care needs. Instead, investigators say patients typically have urgent or emergent concerns, regardless of their insurance status. Experts suggest that rather than trying to keep patients out of the ED, cost-control efforts should focus on establishing better referral systems of care. ⋯ For frequent ED users, the distribution by payer type tends to reflect the community. Similarly, the most common diagnoses for frequent users are similar to that of occasional users. According to one study, while Medicaid patients use the ED roughly twice as often as patients with private insurance, the triage decisions for these patients show that they have urgent or emergent concerns.
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To cut down on diversion time, Denver Health Medical Center in Denver, CO, decided to locate a hospital medicine team in its ED (HMED). The HMED team focuses on streamlining patient flow as well as caring for patients boarded in the ED. The approach has proven successful, slashing diversion by 27% while also increasing discharges from the ED by 61%, according to a pre and post study of the intervention. ⋯ Emergency department physicians say having immediate access to an admitting team streamlines the admitting process and helps to ensure that patients are sent to the most appropriate floors for care. A successful HMED intervention requires commitment to the approach from hospitalists, and a willingness among ED staff to have a hospitalist team located in the department, according to hospital sources. A productive relationship between ED physicians and hospitalists is key.