EM Blog - EM-Blog - The “No-wait ER” by Tom Scaletta, MD

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Mar222010

The “No-wait ER” by Tom Scaletta, MD

Monday, March 22, 2010

Tom Scaletta, MDAn interesting term has migrated into the parlance of emergency department operations – the “no-wait ER.” A basic clinical scenario will illustrate a few points about this concept. Consider a patient on warfarin that sustained a moderate head injury and complains of a mild headache. Her neurological exam is normal. An INR and CT scan are ordered. The CT is normal, the INR is 2, and the patient is discharged. The key ED process divisions and expectations for this patient include:

Intake: Rapid triage, immediate bed placement
Clinical: Blood drawn, INR and CT ordered and completed, CT interpreted
Depart: Results discussed, patient discharged

Best practices for the above scenario include the following intervals:

Door-to-doctor: 30 minutes*
Doctor orders: 5 minutes
CT completed: 45 minutes*
CT interpreted: 20 minutes*
Depart process: 20 minutes*

*derived from the EmEx-Compare ’Excellent Thresholds’ (best practices)

For problems that necessitate laboratory and radiology testing, efficient EDs may require a cycle time of 2 hours. The term “no-wait ER” really means that that all waiting is appropriate, that there is no unnecessary down time and that there is constant forward momentum. Patients tolerate what they perceive to be reasonable waits in any service industry.

How would you feel walking into a nice restaurant, getting seated in a couple of minutes, and then waiting an hour before someone took your order? This is analogous to having a good ED intake system and either being understaffed with physicians or having an adversity to nurse-initiated, standing orders. Conversely, you might not appreciate the maître d’ taking your order upon arrival and then standing up at the bar to dine. This parallels putting a physician at triage to treat all those vertical because the treatment area is displaced with all those horizontal who are awaiting inpatient beds.

Great service in any industry requires adequate resources such as staffing, space, and systems. High-functioning EDs have intake systems that produce a door-to-bed time within 15 minutes, assuring the ability to achieve a door-to doctor time within 30 minutes. This requires pre-registration and rapid triage be completed within a couple minutes. When beds are open, patients are brought directly back into the treatment area. And, even when the ED is “full,” all emergent (ESI 1 and 2) cases are immediately bought immediately back, which requires someone is temporarily moved to a hallway space. In this model, the physician participates at intake only at the nurses’ request to address a particular need. Mostly, the physicians remain in the treatment area with the sickest patients.

There are always periods when waiting must occur. For instance, an unstable trauma case may require an hour of one-on-one physician and so other patients will wait for dispositions. The ED staff recognizes this as necessary waiting while patients are generally less forgiving about who else is in the ED.

Reactive solutions sometimes try to force a “no-wait ER” upon a distressed ED. Not surprisingly, the drivers include intolerable LWBS rates (lost revenue), severe customer dissatisfaction (poor reputation), and safety concerns (waiting room tragedy). Some respond by repositioning a practitioner to triage to see ambulatory patients in cubicles and perhaps even refer away some non-urgent cases. The waiting room becomes used for patients in progress usually because no hospital-wide solution has been found to eliminate inpatient boarders. While appropriate in desperate circumstances, such reactive solutions should not be misconstrued as ideal.

In summary, the “no wait ER” is a misnomer. The best EDs encourage constant forward momentum and curtail unnecessary waiting in an elegant manner through adequate resources and optimal processes. Distressed EDs often shift the doctor to intake imparting a necessarily reactive solution to suboptimal conditions.

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Reader Comments (19)

One of the answers to improving throughput, for patients whose problems are not complex, is not to use beds. The patient in your example has a low complexity problem - in other words, the diagnostic steps are obvious at the time of arrival, and the patient does not need intensive nursing care. So, put her into a fast-track stream where patients remain in their clothing and rest in recliner chairs - not beds. The same patient can have blood drawn and go to CT without ever getting into a bed (presumably she is well enough to go home if the tests are OK). By streaming according to problem complexity rather than urgency, up to 30% of cases can go into a rapid turnover system, without ever lying in bed.

Of course, bed block has to be fixed by the rest of the hospital so that admitted patients move to the wards. However, streaming by low complexity goes certainly improve transit time for those discharged from ED - they are the ones we have control over.

Sue Ieraci

March 22, 2010 |

Sue Ieraci

Sue,
I agree with you and it seems you are certainly making the point that Constant Forward Momentum is the right theme. Any time you can move testing upstream (or minimize exam room time) then you reduce length of stay.

Here is a related article from the latest EmEx newsletter, "Excellence Matters" -- http://www.emergencyexcellence.com/newsletter/march_2010.htm.

Tom

PS - If anyone wants to sign up for the newsletter, you can do so at http://bit.ly/761tXC.

March 28, 2010 |

Tom Scaletta

The main problem is - lack of beds and personell. And abuse of the system. We've instituted a no wait ER and it only made things worse. One patient checked in for a very non emergent problem- when asked why she didn't just go to her doctor's office across the parking lot, she replied" Oh- it's faster and easier to just come here instead of making an appointment and waiting" ? If you routinely have patients waiting hours to be seen, it means you have insufficient staffing and beds. But the fix to that is expensive and hospitals do not want to hear that !

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