Pulse
No Room in the ER
Is the emergency department overcrowding crisis over?
When Helen Strike signed on as vice president of patient care services at Fairview Ridges Hospital in Burnsville last spring, long waits for care in the emergency department and calls to divert ambulances to other facilities in the metro area had become all too common.
In 2003, the hospital led the metro area with 93 emergency department closures that lasted a total of 305 hours. Between January and May of 2004, Ridges closed 39 times for nearly 121 hours—more time than any hospital in the Twin Cities. “We see about 43,000 patients a year in the ER of our 150-bed hospital,” says Strike. “That’s a very large front door.” She attributes much of the volume to the fact that the hospital is the largest one south of the Minnesota River and serves Lakeville—one the fastest-growing communities in the Twin Cities metro area, Burnsville, Apple Valley, Eagan, and Farmington.
Although Ridges’ numbers have been high, the situation isn’t nearly as bad as it was in 2001—the year temporary emergency department closures peaked in the metro area. The Medical Resource Control Centers, which monitor emergency department closures at 22 hospitals in and around the Twin Cities, reported 1,349 closures that year, including 116 at Ridges. “Everyone looked at 2001 and realized that something had to be done,” says Brent Asplin, M.D., M.P.H., medical director of the emergency department at Regions Hospital in St. Paul.
Although nearly all metro area hospitals still have to divert ambulances at times, the situation has improved significantly. Between January and October 2004, the Twin Cities area experienced only 293 emergency department closures.
Why the decrease? Asplin attributes much of it to hospitals’ willingness to look beyond the walls of the emergency department. Asplin, who has spoken nationally on the issue of alleviating emergency department overcrowding, explains the problem as one of supply and demand: Hospitals eliminated staffed beds in order to cut costs just as the baby boomers were starting to age and suffer more chronic illness and as consumers were lashing out against utilization control by managed care organizations. “If there wasn’t a staffed bed, patients would go to the emergency department and wait,” he says. And when emergency departments got overloaded, they would close their doors to ambulances.
Regions has improved efficiency by integrating prior clinical information with an electronic tracking system; doing patient registration at the bedside as providers are delivering care; streamlining the way the emergency department staff communicate with staff on inpatient floors; making inpatient rooms more multipurpose by putting equipment for treating eye, ear, or other concerns on mobile carts; reducing turnaround for beds, lab, and X-ray results; and reducing variability in the way emergency department staff handle certain situations. “When the emergency department was full, some combinations of staff would go on divert almost every time where others did not,” Asplin says.
These measures have helped reduce the time between a patient’s arrival and initial evaluation from 40 minutes in April of 2004 to 20 minutes in November.
Hennepin County Medical Center (HCMC) in Minneapolis has cut down on the amount of time emergency patients must wait to be admitted by 30 percent by simplifying the process of getting the patient into a bed. “The old process took eight to 26 phone calls to get a patient to the bed because a variety of people needed to be called—from housekeeping to the nursing supervisors,” says Kelly Spratt, associate administrator for emergency services at HCMC. Now, the admissions department serves as mission control for bed assignments. Department supervisors enter information about bed avail- ability on an electronic spreadsheet that’s accessible to the admissions staff. When the emergency department needs to admit a patient, the staff contacts admissions, which assigns an available bed and informs the house nursing supervisor and the charge nurse on the floor where the patient is going.
Fairview Ridges began tying together its efforts to improve patient flow throughout the hospital last May. Strike says that many strategies have been put in place, such as using teletracking software to increase communication among hospital staff to make sure beds are being turned over quickly and providing different levels of nursing care on general units to keep patients who aren’t critical out of the intensive care unit. As a result of these and other measures, Ridges experienced only six emergency department closures between June and October.
Strike admits the job is far from finished. “It’s a daily battle, especially on long weekends and with the flu season coming. If our hospital is at capacity, we will have to divert our ER,” she says, adding that it’s a challenge all hospitals may face, given the shortage of flu vaccine this year. Although the situation in the Twin Cities isn’t nearly as bad as it is in places such as Los Angeles County, which has seen six emergency departments close altogether over the last 18 months, Asplin believes it could reach code blue status if broader issues aren’t addressed. “We often wait until people are sick enough to need a hospital bed before they become part of the system,” he explains. “We can’t hospitalize our way to better health in this country, and until we start addressing those issues, it’s going to be hard to solve our capacity problems.”—Kim Kiser
Tracking Beds Online
Credit computer technology for alerting emergency department managers to the magnitude of the overcrowding problem in 2001.
Early that year, the Medical Resource Control Centers (MRCC) at Regions Hospital and Hennepin County Medical Center began using EMSystem, a Web-based application to facilitate communication between hospitals and ambulance services. EMSystem allows hospital emergency department staff to enter information about bed availability into a central system. If a hospital needs to close its emergency department to ambulances, a box will pop up on users’ screens at the MRCC indicating that the status has changed. The system then notifies ambulance services and crews about the closure by sending an e-mail, calling a mobile phone, or giving a page.
EMSystem, which tracks bed availability throughout the area in the event of a large-scale incident, also provides information on the number of closures each hospital had in a given month and the duration of those shut-downs. “Since we’ve been tracking closures with EMSystem, there’s been significant pressure for hospitals to decrease their number of closures,” says David Waltz, principal planning analyst for the Hennepin County Public Health-EMS unit.
Starting in early 2005, hospitals will have to fill out an electronic report explaining why they’re closing, Waltz says. The system will assign a numeric score to the reasons for the closure based on factors such as staffing, the number and type of patients waiting to be admitted, the number and acuity of patients in the emergency department and waiting room, wait time in the lobby, and the number of patients coming in by ambulance. Hospitals will be able to use that information to better understand what causes closures and fix related problems; they’ll also be able to compare information across facilities.
“We’ve known hospitals are closing, but we couldn’t say why. Is the ED staff stressed? Is something going on upstairs? Where are the issues? Now we’ll be able to collect data on that,” Waltz says.—K.K.