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(output), they set up new `Acute Medicine Units' which were intended
to continue the acute stabilisation that was started in the Emergency
Department. They attached financial incentives to meeting the four-
hour goal. The initiative was successful in terms of the four-hour
measure, though there were suspicions of institutions `gaming' the
system, including moving patients out before appropriate evaluation
was completed.
The changes were not durable and, in 2010, the target was abandoned,
though the demand tools and acute units persist. What is important
is, in this initiative, there was only one owner of all the elements, the
NHS, and, if its success was modest at best, that does not bode well
for other systems in which there are multiple discrete entities that
must coalesce to achieve a systematic approach.
`BeD hours', not `BeDs'
The Emergency Department is one such discrete entity and it has
control over only one of the elements, throughput. Throughput is
related to capacity the ability to bring a patient into clinical space.
The common measure of capacity is the number of `beds' but, as a
standalone measure, this is insufficient as the true demand is not for
a bed, but for a bed for `x' amount of time. Thus capacity should be
measured in `bed hours', as should demand. If throughput is improved
with a resulting fall in total bed hours, then capacity is created and
created almost for free and, certainly, without capital expenditure.
In a 50,000-visit Emergency Department with an average length of
stay (LOS) of three hours, the reduction of LOS by one minute results
in the ability to get 200 more patients into a bed; five minutes yields
room for 1,000 more patients, about three more per day. At any given
time, in any normally functioning Emergency Department only
about 20 per cent of patients occupying the beds are actively receiving
medical care. The others are waiting and, while waiting, are sleeping,
on the phone, watching videos on some device, or chatting with
family/visitors.
Recall that 80 per cent of these patients will go home and so they
do not, at this given time, need a bed. They need a place to go while
waiting their turn in radiology or for blood test results; they need an
`internal waiting room', i.e. a place to wait after they have been seen
as opposed to before. Their departure from a bed opens it up to the
next patient. Getting the patient out of the bed is the key here, but
even better is not letting them into a bed. Many patients can be seen
in a chair, which takes substantially less room, meaning that the given
space of the Emergency Department can accommodate more patients
at the same time.
With the increased capacity, patients can be brought directly to a bed
and be seen, in the first instance, by the team assigned to the area
(usually consisting of about 12 beds, maximum) thereby eliminating
the delay waiting `to be triaged' and waiting after triage. `Direct
to bed' eliminates triage completely, freeing up valuable nursing
resources to actually deliver care needed as opposed to spending
the time deciding how long the patient can wait before receiving
care from someone else. Patients are seen in the order in which they
arrived.
There remains, however, particularly for safety reasons, the need for
one experienced RN (`the nurse greeter'), not to sort the patients, but
rather to bring the staff's attention to the few ambulatory patients
with a severe or moderately severe level of illness. These patients
go in just as the others but accompanied by the RN who will then
engage with colleagues to ensure that the patient is seen immediately.
With the exception of an active or impending resuscitation or a clear
psychiatric emergency, any patient goes to any bed, with all beds
designed (or adapted) to accommodate any patient.
`time to Doctor'
To survive the tsunami of ever-increasing Emergency Department
visit rates, the result of aging populations in most developed
countries, Emergency Departments must radically improve their
efficiency using the techniques above. At the Brigham and Women's
Hospital, using these techniques, we have made radical reductions
in `time to doctor' and overall LOS (see graph) such that our median
time to doctor is now 12 minutes. These interventions require two
necessary elements: an attitudinal change by the staff who must
always have an empty bed for the next patient and additional staff
of all types, including a `flow manager' who is the task master for
the teams, pushing them to free up a bed, by either discharging, or
transferring to an internal waiting room or short stay observation
unit, those patients who are likely to go home. The cost of this
additional staff is borne by the increased revenue generated (either
by direct payments or through central funding, depending on the
system) as, with the shortened stay, the cost per patient falls.
There is an additional fall-out here, and a positive one. Patient
satisfaction improves radically because the patient's expectation
(to be seen) is met. The single greatest negative impact on patient
satisfaction in Emergency Departments is the wait to be seen.
Virtually eliminating it, by moving whatever waiting time is necessary
until after being seen, removes this great dissatisfier.
Happier patients getting better care at lower cost per patient and
without substantial capital expenditure to quote a Beatles refrain
".....who could ask for more ?" Not even your hospital administrator
could ask for more and there lies the true test...
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