SAN DIEGO – In the opinion of Dr. Kirk B. Jensen, efforts to maximize patient throughput in the emergency medicine department are crucial.
A critical driver in patient satisfaction is how much time it takes for a patient to see a physician upon arrival. "I am not saying that the physician is the most important person in the equation in the emergency department, but from an operational standpoint the goal in your emergency department is to get the physician and the patient together as quickly as possible," Dr. Jensen said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.
Dr. Kirk Jensen
Patient satisfaction surveys are another driver. "We can quibble with the methodology of patient satisfaction surveys but they are clearly here [to stay] and they command our attention and measure our performance," said Dr. Jensen, chief medical officer at Raleigh, N.C.–based BestPractices, a division of EmCare, which provides ED management and staffing solutions. "Patient satisfaction declines as a function of time spent in the ED. The more time people spend with us, the less happy they are."
Another reason to pay attention to patient flow is the threat of malpractice. One review of wait times and claims per 25,000 patient visits at 36 emergency departments in California found that patients who waited more than 60 minutes to be seen were more than four times as likely to file a malpractice claim, compared with those who waited less than 30 minutes. "The longer it takes to see the physician, the more likely you are to get sued," said Dr. Jensen, who was not involved with the study. "There’s a direct, linear correlation. So when you want to get the attention of people on your ED team to rally around throughput and rally around improving productivity, you can always use data on malpractice and the risk of getting sued as a driver for changing behavior."
There is also a financial case for improving patient throughput in the ED. One ED in which Dr. Jensen assisted as a consultant had 40,000 patient visits per year and set out to reduce the average length of stay from 3 hours to 2 hours. "This generated 40,000 hours of new service delivery which meant a potential to see 20,000 more patients," he said. "If your average net revenue is $100 per patient and you can see 20,000 more patients, that creates $2 million in additional revenue for your physician practice and three to five times that for the hospital."
He advises clinicians to think about the path of an ED patient as having a beginning, a middle, and an end, and to look for ways to improve throughput at each juncture. In his experience, the points with the greatest leverage for throughput improvements are on the front end and at the back end. He described the front end as "the fly wheel that makes your ED hum. Focusing on those processes and that operation is critical to getting the kind of patient flow and throughput that you want. There are also opportunities on the back end, especially for those of us who have problems getting patients admitted to the hospital. This requires cooperation from the inpatient members of your team. My recommendation is to start with the front end, achieve some throughput improvement there, and then you are more likely to get the attention and support from hospital administration when you work on the back end."
Dr. Jensen described triage as "a process, not a place. It’s something we do. In a perfect world, triage consists of asking the patient’s name, eliciting a 2- or 3-sentence chief complaint, a set of vital signs, maybe a pain score, and that’s it. It is not a place to do medication reconciliation or to assess and teach about the need for vaccinations."
He advises clinicians to segment ED patients into vertical or horizontal categories. "The horizontal patients are the reason many of us went into emergency medicine in the first place: they’re hurt, sick, or there’s the potential for something seriously wrong," Dr. Jensen explained. "The vertical patients have simple, well-defined illnesses or injuries. We want patients with ankle sprains to get through the ED in 1-2 hours. At the same time, when an 80-year-old gentleman comes in with acute severe abdominal pain, if it takes us 6-8 hours to work up that patient, that’s a good thing. We are providing value-added diagnostic, therapeutic, and observational services. This is about understanding patient flow, segmenting your incoming patient streams, and mapping your care to the needs of those patients."