Katherine "Kitty" Foley hasn't missed JazzFest in New Orleans in 30 years. But last year, Foley tripped over a trailer hitch during the festivities and broke her right wrist. As a nurse, she knew she needed prompt care but dreaded a long and unpleasant wait in a crowded hospital emergency department.
She decided to put up with the pain a bit longer -- at least until the Average White Band finished its set.
When she did get to Ochsner Medical Center, she was stunned. The whole visit took less than an hour – including X-rays, pain medication, a soft cast and discharge instructions to tide her over until she got home to Cary, Illinois.
"I was absolutely amazed," said Foley, who said she is about 60 years old.
Ochsner is one of a growing number of emergency departments trying new approaches to ease crowding. The efforts have added urgency as some experts predict the problem could worsen in coming years. They worry that as millions of people suddenly gain health coverage in 2014 under the new federal health law, they may have trouble finding primary care doctors and will turn to hospital emergency departments instead.
For both patients and hospitals, crowding involves more than inconvenience. Some patients get so tired of waiting that they leave without being seen. That's bad medicine, because they can end up sicker within hours or days.
And it’s bad business, because the hospital is left with lost revenue and unsatisfied customers.
"It's not only the person with a minor illness . . . who leaves," said Mark McClelland, a George Washington University health policy expert working with the Robert Wood Johnson Foundation's Urgent Matters emergency care project. "Someone who is very, very sick, who is at risk for significant problems, can be leaving. They came to you for help, and you failed your mission if they leave."
The hospital efforts to address the problem have ranged from high-tech options such as smart phone programs that let patients compare waiting times at local hospitals to something as mundane as staggering nursing shifts to better match patient traffic. "Fast tracks," or clinics for patients with simple complaints, are also common.
But some hospitals, such as Ochsner, are looking at more fundamental routines, shaking up and re-engineering their procedures. Ochsner, for instance, created an emergency department protocol called "qTrack." The sickest patients still go back immediately to the emergency department's traditional beds, but patients such as Foley go quickly into separate treatment areas with a nice comfortable recliner or to a procedure room for stitches or a cast. They await test results and discharge instructions in a post-treatment waiting room.
Treatment there can move faster and cost less. Foley never had to change into a hospital gown and or get in an expensive hospital bed with high tech monitors. She just had to show the doctor her arm.
"Beds are the most squandered and overutilized resource in emergency departments," said Dr. Joseph Guarisco, chairman of the department of emergency medicine at Ochsner.
The Banner hospital system based in Phoenix uses a similar approach and was highlighted by the federal Agency for Healthcare Research and Quality as an instructive case study for other hospitals.
Among the changes some other hospitals have tried:
--The emergency department at Stony Brook University Medical Center in Long Island, N.Y., grew tired of having the hallways lined with patients on gurneys who needed to be admitted to the regular medical or surgical floors. But it now has procedures to send some patients upstairs anyway, even if it means they lie on a gurney in the hallway near the nursing station. That has helped the rest of the hospital become more attuned to the needs of the emergency department – and much faster at finding the needed beds, according to Dr. Peter Viccellio, clinical director of emergency medicine.
"It's like a fire alarm that goes on at the institutional level – everyone knows there’s a problem in the emergency department, we're at capacity," he said.
--Doctors at Providence Hospital in Washington, D.C., used community health workers to identify emergency patients who with a little guidance could get their needs met in a community setting such as a primary care, HIV/AIDS or mental health clinic.
"They did a fantastic job of decreasing the return revisits," said Dr. Kim Bullock, the hospital's assistant director for the emergency department. But the project ended when the year-long grant ran out. Under traditional fee-for-service payment plans, Providence has no way of getting reimbursed for the work. The hospital is looking for another grant – or waiting to see whether payment changes expected under health reform make programs like this more viable in the next few years.
--Emergency physicians at Good Samaritan Hospital in West Islip, N.Y., on the South Shore of Long Island, take over one of the hospital's walk-in surgery units after it empties out around 4 p.m. – just in time, because the emergency room generally starts getting crowded by mid-afternoon.
In addition to offering space, the program focuses on patients who score in the middle of the five-point triage scale, whose risk is just not clear cut and who are often at risk for leaving without being seen. For example, does that patient have severe stomach flu – or is it an ectopic pregnancy or a bowel obstruction? An intense migraine – or a brain bleed?
It's not clear that initiatives such as these can keep up with the growing number of patients in emergency departments, especially as some hospitals close and demand continues to grow from the ranks of people newly insured and an aging population. In addition, there is no one easy answer for hospitals--sometimes projects that are hugely successful in one hospital flop somewhere else.
Yet even as emergency departments work on new initiatives, some experts argue that attention should be focused instead on the hospital as a whole. Dr. Art Kellermann, a Rand Corp. scholar and an emergency care physician, says such "workarounds" let hospitals off the hook. "The reality," he said, "is the rest of the hospital doesn't want to deal with the fact that the overcrowded ER is a sure absolute sign of a poorly managed hospital."
Not all experts share that view. "It all depends on where you create bottlenecks," in the inpatient side or in the ED itself, said Dr. Joseph "Jody" Crane, an emergency physician at Mary Washington Hospital in Fredericksburg, Va., and a faculty member of the Institute of Healthcare Improvement. "It doesn't make sense to point fingers," he said.
Foley came away a believer. "I thought it would be five or six hours --- two hours to get in, another few to get out." Instead "I iced and elevated my arm like they told me to – but I stayed for the rest of the JazzFest."