ED keeps everyone happy with innovative space use
Waits down during busy flu season
When flu season hit the San Francisco area this past winter, portending the period when overcrowded emergency departments frequently go into "ambulance divert," UCSF Stanford’s Moffitt/Long Hospitals had a plan ready to deal with the problem, says Dale Borgeson, MBA, business manager for emergency medicine.
By making use of nearby space — at an adjacent clinic and at the hospital’s endoscopy recovery bay — the emergency department (ED) that serves both hospitals dramatically reduced the percentage of time ambulances were "diverted" from bringing in emergent patients, Borgeson says.
At the same time, he adds, the ED cut the wait time for "urgent but not emergent" patients from about 3.5 hours to between 1.5 and two hours.
"Throughout flu season, there is a high hospital and ED census," Borgeson explains. "Last year [1997-1998], this was a big problem at all the receiving hospitals in the San Francisco area, and a lot were going on ambulance divert. The county emergency medical service agency was very concerned because this restricted access to care for ambulance patients."
Another concern, he says, was that the hospitals lose business when on divert — about 45% of ambulance patients end up being admitted.
Staff developed prevention strategies
Working with hospital administration, ED staff developed a divert prevention effort, aimed at staying open during winter flu season, using these two strategies:
• Borrowing space at an adjacent clinic during evenings, weekends, and holidays, the ED staff created a "fast-track" unit for urgent but not emergent patients. Physician extenders — physician assistants (PAs) and nurse practitioners — were able to see these patients more quickly while freeing ED beds for the more critical ambulance patients.
• Again borrowing after-hours space, this time in the hospital’s endoscopy recovery bay, ED staff established a holding area for stable patients who were waiting to be admitted to the hospital. "Because this is a teaching hospital with a resident interface, a consult team has to come down, do the paperwork, and take the patient upstairs," Borgeson explains.
There is often a two-hour delay while the patient to be admitted occupies a bed in the ED, he adds. Meanwhile, the ED beds may be full, requiring staff to put patients on gurneys, Borgeson points out.
"We decided that we would take patients who are stable and who are being admitted to medicine to the endoscopy recovery bay, where there are cardiac monitors, and staff that area with ED nurses," he says.
As a result of the divert prevention program, Borgeson notes, the Moffitt/Long ED reduced its time on divert for all three of the "winter flu" months, as follows:
• from 7% in December 1997 to 2% in December 1998;
• from 14% in January 1998 to 5% in January 1999;
• from 6% in February 1998 to 1% in February 1999.
The ED is open 730 hours a month, he adds, so 1% represents about seven hours.
"Even with these two moves, we were over capacity about 20% of the time, but we had a mechanism for clearing patients out," he says. "We didn’t become so bottled up we had to divert. We gained both space and staff because we were authorized to get more physicians and PAs."
The reduced time on divert was achieved even though the patient census went up — 2,900 in January 1999, compared with 2,300 the previous January, he notes. "We saw a lot more patients than we’d ever seen before, and we also reduced overall waiting times slightly, to 3.2 hours from 3.4 hours."
Previously, Moffitt/Long ranked about average, comparing its time on divert to that of other hospitals in the San Francisco area, he says. After the divert prevention program was implemented, its overall time on divert was about 2%, compared with between 8% and 10% for the other area hospitals, he adds.
Despite the dramatic reduction in divert time, the borrowed space is less than ideal, Borgeson observes. "The main drawback is that on busy weekdays, we couldn’t get in until after dark. We’re trying to get permanent space to have room for the fast-track clinic as part of the ED, and to have our own holding unit."
Plans eventually are to have a separate observation unit, where patients could be held up to 12 hours before an admit decision is made, he adds. Such an area would take the place of the current holding unit. "With a good observation unit, you only admit about 30% of those patients. You save the expense of an admission and provide better care. It saves on admissions that are not appropriate at a time when the census is really high."
At present, when the adjacent clinic is not available for fast-track patients, some of the rooms in the ED are designated for that use, with physician extenders assigned to those rooms. "That works OK when we’re not so busy, but by mid-afternoon it’s more congested," he says. "We have to decide on space use depending on the urgency of the patient. That’s when the waits occur."
Patient satisfaction scores have been high among those served by the fast-track clinic, Borgeson reports. "They’re very grateful they can be treated and sent home without waiting for the urgent patients to be seen. About 30% [of ED patients] are new to the medical center, so that makes a good impression."
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