"Waiting Time: Guaranteed 30 minutes or Less” is a
promise some emergency departments (ED’s) have a difficult time
delivering. Why is that a problem? I hope I’ll be able to satisfy this
question for you in the next two issues of the “Academy Corner”.
The specialty of Emergency
Medicine “emerged” in the early ‘70’s. Prior to that, staff physicians on
call for a certain hospital would care for their own patients in the “ER”
when they became acutely ill. Often there would be no physician on-duty,
or actually in the ER, at all. As physician specialization became the rule
rather than the exception, there was found to be a need for an emergency
medicine (EM)specialist--a physician trained in handling emergencies of
any medical sort, patients of any age-- and their care be available 24
hours a day. As the number of patients being seen and evaluated in the
emergency “room” increased, these areas needed to expand to become the
emergency “departments” or “centers” we have today.
When I became an attending EM
physician in 1989, it was unusual for any patient to wait more than 20
minutes to be seen by a physician. (Of course, critically ill patients
were always seen immediately, sometimes simultaneously in adjacent beds!).
In that 18-bed emergency department, over a 12-hour shift, many of those
rooms would often remain empty. Oh, but have things changed since then!
The number of uninsured
Americans has risen; many of the uninsured do not have an established
family doctor and so use the ED for routine medical, as well as emergency,
care. This often forces the EM physician to do extensive testing on
patients that do not have an established means of getting those tests
ordered as an out-patient. This is time consuming and ties up a bed in the
ED, sometimes for many hours. Without routine care, many patients also
often delay investigation of a medical complaint until it has reached the
crisis stage. This requires even more testing and intense, time-consuming
one-on-one attention by the physician in the ED.
Even if patients are insured,
their insurance plans often dictate where the patients may seek emergency
care and thus steer patients into one emergency system, often in an
unbalanced pattern. Many busy primary care physicians’ offices do not have
the capacity or time to see all of the patients who call each day trying
to be seen immediately. How many times have you called your physician’s
office only to hear the recording: “If this is an emergency, call 911 or
go to the Emergency Department?”
Busy lifestyles of all Americans
make it more attractive or convenient to visit an ED during evening hours
rather than schedule a visit with a family doctor during the day. Many
people simply have a difficult time getting excused from work or school
for either acute or routine medical care during normal working hours,
leaving them nowhere to go other than an emergency department or urgent
care center for care.
All of these factors add up to
one thing: increased demand for emergency department services by the
population. In next month’s column, I will take you through an imaginary
patient’s emergency visit and discuss what takes so much time to actually
receive those services!
PART II
In last month’s issue of the Academy Corner, I outlined the history of
emergency medicine as it has evolved over the last 40 years and how the
numbers of patients seeking emergency care impacts the system. Now I’ll
take you through a patient’s visit to the ED and see how internal
processes can make these visits take so long!
Mary has been suffering from intermittent abdominal discomfort for a
year and a half. She has had visits to her family doctor, out-patient
tests including x-rays, lab tests and pelvic exams with the diagnosis of
irritable bowel syndrome given to her. Tonight her nagging pain is back
again, only a little worse this time. She wonders if the doctors have
missed something. So, Mary decides to go to the ED to be “checked out.”
Arriving at the ER, she fills out a slip of paper that lists her name
and time of arrival, and the reason for her visit. “8:30 pm. Abdominal
pain.” This paper is given to the triage nurse, who will talk to her, take
a history of her complaint, obtain vital signs (pulse, temperature, blood
pressure and respiratory count), and make a list of her medications. With
this information, the triage nurse evaluates what priority Mary has in the
ED. However, two other patients arrived just a minute or two ahead of Mary
and so the triage nurse is seeing them first. Mary finally gets to see the
triage nurse at 8:45pm. This process takes about 10 minutes. It’s 8:55 pm
and there’s an available ED bed and so Mary is escorted back to Room 15.
Things are looking good.
In Room 15 a clerk comes in to register Mary. Her address, insurance
information, next of kin and referring physician are all noted. It’s now
9:05 and she is greeted by her nurse, who reviews the information given to
the triage nurse, elicits other pertinent information and examines the
patient. Hopefully by now, the official chart is available from the
registration clerk, and Mary can be seen by the physician. It’s 9:15 pm.
At 9:20, Dr. ER takes Mary’s chart from the rack and walks toward Room
15. About half the way there, Dr. ER hears an overhead page calling him to
the nurses’ station for a phone call. He had paged Dr. Orthopedist 20
minutes before about a patient that needed an admission for a fractured
hip. He explained the case to Dr. Orthopedist, who wanted the patient
transferred to another hospital. Dr. ER hung up and after finding the
patient’s nurse, asked for her to arrange for the patient’s transfer. Now
it’s 9:25 and he’s heading back to Room 15. But on the way there he stops
in Room 10 to tell that patient he’ll be being transferred to Dr.
Orthopedist’s hospital. There’s a few minutes discussion about that, and
at 9:30 he’s arriving to talk to Mary!
After taking Mary’s history and examining her, he decides he needs to
do a pelvic exam and wants to order blood tests, a urinalysis and possibly
a pelvic ultrasound. He takes her chart, makes a few notes on it and walks
back to the nurse’s station. He places the chart in the rack on the unit
clerk’s desk, behind three other charts. The unit clerk will enter the
necessary tests ordered on a centralized computer, so that the laboratory
tech will know there is blood needed to be drawn in Room 15. It’s 9:55 and
the lab tech is drawing the blood. Mary doesn’t need to urinate, and so
that specimen will have to wait.
At 10:00 the nurse and doctor return to complete Mary’s pelvic exam,
and it is determined that Mary does need a pelvic ultrasound. This is
“after hours” and so the ultrasound tech needs to be called in from home—
and so the tech is paged, returning the call at 10:15 and states she’ll be
at the hospital at 10:35 pm. A foley catheter is placed in Mary’s bladder
for the ultrasound, and that urine specimen is finally sent to the lab for
analysis.
Mary returns from ultrasound at 11:10 and we wait for the radiologist’s
report. At 11:30 the report is faxed and the diagnosis is an ovarian cyst.
However, this finding doesn’t really explain her abdominal pain, and so
Dr. ER decides to re-evaluate the situation. He re-examines Mary, her pain
is still present, but hasn’t changed in intensity or location. After
evaluating the results of the blood tests and urinalysis, it’s decided to
admit Mary to the hospital for observation and surgical consultation in
the morning, with a diagnosis of possible appendicitis. So at midnight,
her family physician is paged to direct the admission to the hospital. The
admission department is called to obtain a bed for Mary. Admission orders
are obtained at 12:30. At 1:00 am Mary is being wheeled to her hospital
bed---four and a half hours after arriving at the ED!
As can be seen, evaluation of a patient in an ED consists of many
steps. This process is being repeated by every patient seen, and it’s a
constant juggling act for physicians and nurses to maintain the flow of
care. Just a few extra minutes in any step along the way can remarkably
alter the total time a patient spends in the ED. Critically ill patients
and those patients with potentially serious complaints are always seen
rapidly. At the same time, those very ill patients require a lot of
one-on-one care by the physicians and nurses, often requiring those less
ill to wait for care. Hospital administrators and ED staff are continually
looking at the process to find ways to streamline patient visits and yet
maximize the quality of care provided. Best advice when visiting the ED?
Take a good book along and be prepared to sleepover!
Diane McCormick MD
Academy of Medicine of Toledo
and Lucas County
