Patient congestion in ED

Patient Congestion in the
Emergency Room
How the patient is a solution to the
problem
Dr Ashraf Amin Ahmed – Psychiatrist and Chief Medical Officer
Dr Jonathan Bankoff – Emergency Medicine Physician and Medical Director
Dr John Baron – Nephrologist and Associate Chief Medical Officer
Nurse Melissa Walter – Maternity Nurse and Chief Operations Officer

ED’s are stretched thin
Barish, Robert A et al. Emergency Room Crowding: A Marker of Hospital Health. Trans Am Clin Climatol Assoc 2012; 123: 304–311.

More visits in less EDs

Disproportionate use of ER services for
acute care

Reduce ED congestion through
patient involvement in service gap
closure
• Listening gap
• Planning Gap
• Service Delivery Gap
• Communications Gap

Listen to those with answers
• Patient discussion groups
• Hear from the patient about what troubles them
• Online patient discussion blog
• Monitor and facilitate
• Patient advisory counsel
• Vet policy and procedural change
• Leadership bedside patient rounds
• Keep the ear close to the ground
• Leadership – Staff Bulls and Bears
• Determine problems and brainstorm solutions
• Focused patient feedback
• Brief questionnaire at point of service
Graphic from SBG pg 45.

• Train staff to listen
• Intentional listening at each moment of truth
• Develop facile software program to log, organize
and review
• Train staff in service recovery
• Emphasize and reinforce RATER
• Responsive, Assurance, Tangibles, Empathy,
Reliability
• Ensure staff members empowered with recovery
options
• Develop “listening” subcommittee
• Recurring meeting with formal agenda that reviews
• Report to superior committee regularly

And Above all…
Stress the importance of active listening and demonstrating
empathy and compassion with each encounter.
In many cases, an ear is all it takes to diffuse a situation.
Always offer sincere thanks for a customer’s time to speak
with them regarding their experience.

Design the ED for success
• Much of health care gap management centers on
managing patient expectations and involving the
patient in their care
• How well we meet patient expectations
determines patient satisfaction
• Involving the patient in their health care and
designing our care delivery around these
expectations
leads to improved quality outcomes
• Closing Gap 2 helps close other gaps and
improves
the experience
Graphic from ZBG pg. 45.

• In the ED, much of our success is
determined by well-thought out
design
• One of the greatest challenges in
EDs today is demand and capacity.
– We often run out of room to see
patients due to long lengths of stay,
boarding, and inappropriate use of the
ED for non-emergent presentations
– To succeed, we need to better match
supply to meet increasing demand and
help educate our patients to better use
available resources
– We must design the ED for maximum
efficiency and then ensure that our
patients use it properly

• Methods / Designs for improving ED
efficiency
– Parallel processing, not serial: bring
resources to the patient, rather than
making them go through a step-by-
step process
– Bedside registration
– Use of an Express Care area for low
acuity patients
– Placing an ED Provider in Triage to
expedite workups / shorten LOS
– Implementation of RN protocol
orders to expedite workups /
shorten LOS
– Triage Kiosks in the ED WR
– Online wait time clocks and ED
appointments to smooth patient flow
– Streamlined IT services / EMR for

• Methods / Designs for improving ED
patient efficiency
– Ensure proper use of the ED by patients by
keeping them informed of options and
soliciting their feedback to improve
processes
– Keep non-emergent / urgent patients
moving vertically out of the ED
– Increase utilization of Urgent Care Centers
and Primary Doctor’s offices
– Increase use of PAs and APRNs whenever
possible
– Improve access / availability of UCC and
PCP offices with extended hours (nights /
weekends) to limit unnecessary use of the
ED
– Educate our patients and community with
the help of patient navigators, nurse

Run the ED for success
• Get the right people on the bus!
• Generally, skill can be taught. Thus, hire for
service disposition – do they possess a “RATER”
mindset?
• Hire hard, train easy
• Train the right people
• Develop and execute best practice service
delivery methods
• Ensure ongoing competency training and
focused “touch-up training” as needed
• Retain the right people
• Spend 80 percent of your time on your dream
team, and 20 percent on those who need to get
on another bus.
• Develop a recognition program for
strong performers.
• Develop an ongoing
mentoring/coaching curriculum – the
front line staff is leadership’s patient!
• Empower your dream team – don’t

Manage supply and demand
Track hourly, daily, weekly, and monthly ED census
Review trends over the past year
Increase supply
Hire locums/traveling nurse during peaks
Utilize a hospital “float RN” system to respond to unexpected demand
Pay overtime for staff to work on off days
Decrease demand
Ensure patient education in triage
Ensure strong triage system in waiting room to
divert to PCM/Urgent care
Ensure PCM clinic “on call” to handle during and
after hours non emergent medical care
Ensure patients have real time feedback on wait time
based on chief complaint
Develop and execute Utilization Review Committee
Review supply/demand/resource utilization appropriateness

Ensure the patient fulfills his role!
-Encourage them to seek care at the appropriate
location
-If at the ED waiting room and triages as non
emergent, help them obtain same day PCM
appointment/urgent care
-Post patient comprehension-level data and discuss
as required reduction of care quality in crowded EDs.
-Develop and execute a “coping” program for those
who recurrently utilize ED services
inappropriately(contracts, divert options)

Avoid problems with service intermediaries(Urgent Care,
PCM’s)
Spend time with key stakeholders to ensure patient are
able to
receive care at the appropriate triage level(ED, UCC,
PCM)
Develop an Acute Care Utilization Review Committee
Staffed by key ED, UCC, PCM staff
Agenda focused on right provider right location right
time

Communicate for success
Integrate ED congestion solutions
Remove silos between departments and instead
maintain an intricate neuronal network of collaboration
between ED staff, PCMs, Urgent Care clinics, and
patients. The more we communicate the better we are!
We must all speak the same language so our message
to each other is intelligible and consistent. This is
achievable through Gap 1, 2, and 3 action plans.
Manage Customer Expectations
Ensure patient education of most appropriate use
of health care resources
Demonstrate, though data and story telling, the harm
associated with ED crowding as addressed in gap 3.

Communicate for success
Communication “static” is still the number one cause
of medical errors!
Repeat, restate, reiterate

Using Gap analyses with the
patient as the focal point, let’s
“resect” chaos

Using Gap analyses with the patient as the
focal point, let’s “resect” chaos

Patient congestion in ED

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