Categories
Emergency Department

Diversion Is Deadly

Every day, I get an email with all of the statistics from the previous day’s emergency department activity. The one statistic that can drive me crazy is the emergency department diversion hours. These occur when the ER goes on “divert” status which means that emergency squads are told to bypass our emergency department and take patients to some other hospital’s emergency department. We never close the emergency department and patients can still walk-in to the ER normally.

There are several reasons that the ER can go on divert:

  1. The ER itself is overwhelmed (for example, multiple critically ill patients arrive at the same time)
  2. We don’t have any empty beds on the nursing units to admit patients to from the ER
  3. We don’t have any ICU beds to admit patients to from the ER
  4. We don’t have enough inpatient nurses to take care of more admissions

Diversion is bad news for several reasons. First, and most importantly, it means that our hospital does not have the resources to care for the patients in our community at that particular time. A patient who lives 5 blocks away should not have to be taken to another hospital 15 miles away where their family and friends cannot easily visit. Second, it disrupts continuity of care. Patients who always get their care in one hospital and whose physicians practice at that hospital are best served by being taken care of by the doctors who know them the best. Third, it is bad business. Hospital admissions are the fuel that keeps the hospital running and patients arriving by squad are far more likely to be admitted to the hospital than those who walk in through the front door who are more likely to be treated and released.

Last year, our ER diversion hours reached record highs. Rather than being a rarity as it had been for more than a decade, it was becoming a regular occurrence, at least once a week. Our initial solution was to open up 4 new ER beds and 5 new inpatient beds to avoid the “no room at the inn” phenomenon. That helped but didn’t solve the entire problem entirely. So next, we asked the 5 whys.

The 5 whys was a concept developed by the founder of the Toyota Corporation, Sakichi Toyoda. His idea was that if you identify a problem, then you keep asking why it occurred through 5 layers of inquiry in order to get to the root of the problem and solve it. So, for example, you identify a problem that your medical students are passing out when holding retractors during pancreatic surgeries.

  1. Why are the medical students passing out? Because they are hypoglycemic.
  2. Why are they hypoglycemic? Because pancreas surgeries go on for 5 hours and the medical students haven’t had anything to eat.
  3. Why don’t they get something to eat before the start of surgeries? Because they are pre-rounding on their patients until 8:00 AM and all of the donuts in the physician lounge are gone by 7:00 AM.
  4. Why are all of the donuts gone by 7:00 AM? Because the donut company only brings 3 boxes of donuts even though the administrator in charge of donuts always orders 8 boxes of donuts.
  5. Why do they only bring 3 boxes rather than 8 boxes of donuts? Because the donut administrator always fills the donut order out in blue ink and faxes the order to the donut company and since the blue ink doesn’t fax well, the “8’s” look like “3’s”.

So, what is the solution to the syncopal medical students? Buy the donut administrator a pen with black ink.

We applied this principle to our emergency squad diversion problem. First, we looked at the what days of the week we were going on divert and found that over the course of a year, diversion hours peaked on Wednesdays, pretty regularly and pretty dramatically on Wednesdays. In contrast, diversion was very rare on Fridays, Saturdays, or Sundays. Next, we looked at when our emergency department admissions peaked and it was on Mondays, again, pretty regularly and dramatically peaked on Mondays. Next we looked at when our elective surgery admissions peaked and it was on Tuesdays, very consistently on Tuesdays.

So the solution wasn’t to bring in extra ER physicians on Wednesdays or open additional inpatient beds on Wednesdays. The solution was to move one of our busiest orthopedic surgeons from operating on Tuesdays to operating on Thursdays. What had been happening was that we would get a bolus of emergency department visits on Mondays followed by a bolus of joint replacement surgery admissions  on Tuesdays and then by Wednesdays, we’d be out of inpatient beds. By Fridays, the Monday and Tuesday admissions would be ready for discharge and then we’d have excess inpatient capacity through the weekend. By moving the orthopedic surgeon to Thursdays, we evened out the admissions over the course of the week and presto, the ER diversion hours plummeted.

The 5 whys can keep you from making stupid decisions. Getting back to our medical students who were passing out in the OR, if we had stopped with the first why, we may have banned medical students from holding retractors. If we had stopped with the second why, we may have told the surgeon that he needs to finish his pancreas surgeries in 4 hours. If we had stopped with the third why, we may have required the medical students to come in an hour earlier to do their rounding. If we had stopped with the fourth why, we may have fired the donut company. It was only after the fifth why that the solution of buying a 99¢ black ballpoint pen to fix the problem became apparent.

December 17, 2016

 

Categories
Emergency Department

America’s Increasing Suicide Rate

suicide-in-the-usSuicide in the U.S. is increasing. It is the second leading cause of death for people age 10-34 and the tenth leading cause of death overall. Americans favorite method of suicide: firearms. One of the reasons for our country’s increasing suicide rate is the declining number of psychiatric beds compared to other nations. The Organisation for Economic Cooperation and Development (OECD) is a group of the top 35 industrialized countries in the world. A recent study analyzing the U.S. suicide rate found that it correlates perfectly with our declining psychiatric bed availability. Since 1998, we have had a 35% drop in the number of psychiatric beds. At the same time, we have seen a 24% increase in suicides.

In the U.S., there are 22 psychiatric beds per 100,000 population. The average world-wide is 72 per 100,000. Only 4 other countries have fewer psychiatric beds per capita than the United States: Italy, Chile, Turkey, and Mexico. Our annual suicide rate is 13 per 100,000 population which is high compared to the global average of 11.4 per 100,000.

It is not because we are psychiatrically healthier. Here in Central Ohio, our psychiatric beds are almost always full. This results in psychiatric patients backing up in our emergency departments, waiting to be admitted. Last week, for example, when I got in to work, we had 11 patients in the ER who were “psych holds”, that is patients who were determined to be at too high of risk of causing harm to themselves or others to release. They occupied 38% of all of our ER beds. Because each of these patients requires a “sitter” to watch them to ensure that they do not harm themselves or leave the ER, it ends up being an enormous use of hospital staff and resources.

The time suicidal patients spend in the emergency department is often wasted time. There are usually not psychiatrists, counselors, and social workers who can initiate the psychiatric care that the patients need. The patients are psychiatry purgatory, waiting to go somewhere that they can get their treatment.

As a society, we are under a constant demand to increase emergency department beds in order to meet the needs of our communities. Perhaps our first step should not be increasing ER beds but instead, increasing psychiatric beds. Surely the greatest economic powerhouse nation in the world can at least strive to be average in psychiatric care.

November 9, 2016

Categories
Emergency Department

Guns, Guns, Guns

gunYesterday, a man was shot a couple of miles from our hospital. Not an unusual event, people get shot every day in America’s large cities. Our hospital is not a designated trauma center but we still have gunshot victims dropped off at our front lobby by their friends – either they die in our ER or we stabilize them and send them to one of the regional trauma centers in Columbus. Guns are a way of life in our city, as they are in all cities in the U.S. We require all patients to go through metal detectors to get into the emergency department – as do all hospitals in town – and finding guns is not uncommon at the metal detector. We require anyone with a weapon to hand it over to our security personnel until they leave – a lot like an old west saloon.

Shootings and murder are commonplace in the United States. We kill each other more than any other first world nation and we are right up there with third world countries where a murder doesn’t even make headlines. We’re pretty good at the detective work that goes into solving those murders, our problem is that we just have too many of them.

murder-rate-2

 

To kill a person, two things have to happen. There has to be someone who wants to kill someone else and they have to have an effective way of killing. So, if killing another person requires both intent and an available method, which of these is the reason for the United State’s exceptionally high murder rate compared to peer countries? I’d like to think that it is not because Americans are full of more hatred than other industrialized nations.

A gun is a highly effective way to kill someone and we have too many of them. Guns are everywhere in the United States. We have more guns per capita than any other country on earth. In fact, we have more guns than we have people in our country.

guns-per-capita

What is the answer? I’m not any smarter than anyone else. But solutions need to start with what we agree on instead of starting with what we disagree on.

I think everyone in the U.S. would agree that a person shouldn’t be able to walk into a sporting goods store and by a nuclear weapon. But almost everyone would agree that a person who wants to go duck hunting should be able to buy a shotgun.

Everyone would agree that someone who was previously convicted of felony armed robbery and is also a card-carrying member of a terrorist group should not be allowed to buy guns. But almost everyone would agree that a law abiding citizen with no criminal record should be allowed to buy a gun.

We agree with the extremes of gun control. What we disagree with is where the line needs to be drawn in the middle. By spending all of our political energy on fighting each other in courts and legislatures about exactly where that middle line is for gun control, we’ve accomplished almost nothing. If we instead started with the fringes of the gun control debate and tried to figure out on what we can agree on, we might actually get something accomplished.

Don’t get me wrong. I’m not a raging liberal out to pry guns from everyone’s hands. I used to be a member of the NRA (when I perceived it as being an organization primarily dedicated to gun safety and recreational hunting rather than a lobby group for gun ownership). Some of my fondest memories from childhood were bird hunting with my father in early winter in rural Southern Ohio. And I’ve personally annihilated hundreds of clay pigeons over the decades (with permanent tinnitus as evidence).

But having too many guns and putting them in the hands of the wrong people just creates a lot more work for all of us who keep America’s hospitals working. As it is right now, we just make it too easy to kill each other in our country. For most of Americans, the topic of gun control is polarizing. But if you work in an emergency department or a trauma operating room, the lack of gun control is just exhausting.

Sorry to be up on a soap box about this. But we have to make steps to stop our country from being the murder capital of the Western World. I would much prefer my hospital to focus on treating disease than treating the consequences of motive + opportunity.

October 18, 2016

Categories
Emergency Department

DAWN To Prevent The Dead

heroin-deathsEvery day in Ohio, 5 people die of drug overdoses. We see heroin overdoses in or ER every day. The lucky ones are brought in when they are still breathing and before they get brain damage. The unlucky ones get resuscitated in the ER and make it to the ICU but then die from anoxic brain injury or pneumonia. And the really unlucky ones get pronounced dead in the emergency department. Deaths from heroin and other opioids have exploded in the past few years. State pharmacy boards and medical boards have cracked down on excessive prescription pain medications while at the same time, heroin became cheaper and cheaper. So heroin became the opioid of choice for many drug users. Then it became more powerful with stronger batches of heroin and heroin that was laced with other, even more powerful opioids like fentanyl.

So now we are in the midst of an epidemic of heroin overdose deaths.

Enter Project DAWN (Deaths Avoided With Naloxone). The goals of Project DAWN are to teach people how to recognize the signs of an overdose, how to do rescue breathing, and how to administer intranasal naloxone (the overdose antidote). In order to promote the distribution of intranasal naloxone, you can now buy it over the counter at retail pharmacies without a prescription. It costs about $140 for a box of two doses. The hope is to get naloxone into the hands of families and friends of heroin users who can provide the life-saving heroin antidote before the heroin user stops breathing and suffers brain damage or death.

But the problem is that we often aren’t getting the drug into the hands of those who really need it. Dr. Mike Dick, the Medical Director of our emergency department does know who needs it. It is the people who come into our ER with heroin overdoses. He knew that the best way to keep those persons with heroin overdoses from dying at home was to get the intranasal naloxone into their hands (and their families’ hands). Writing a prescription for it didn’t work – the patients just weren’t going to go the drug store to buy it.

On the surface, the answer seemed simple, dispense it from our hospital pharmacy. The problem is that our hospital pharmacy is an inpatient pharmacy and not an outpatient pharmacy so we can’t dispense drugs. As an example, if we use an albuterol inhaler to treat a patient in the emergency department, we can’t give it to the patient to take with them; we have to throw it away.

So Dr. Dick and our director of pharmacy worked out a way to legally provide patients with heroin overdoses with intranasal naloxone in the ER. For those patients with health insurance, it is usually covered by their insurance. For those patients without insurance, if we give them a dose of naloxone, then maybe we can prevent another emergency department visit that we wouldn’t get paid for anyway. Our hospital became the first in Central Ohio to dispense intranasal naloxone directly to patients in the ER. In July and August, we dispensed 36 doses to patients before leaving the ED. Of those, 81% had health insurance. They ranged in age from 24 to 66 years old. It is too early to tell whether the program is effective yet. We still see overdoses pretty much every day and we still pronounce patients dead in the ER after heroin overdose.

But maybe if we can just save one life…

September 22, 2016

Categories
Emergency Department

Psychiatric Surge

No matter what your political leanings, one thing we can all agree on is that the United States does not have enough inpatient psychiatric beds. De-institutionization of patients with psychiatric disease in the 1970’s has overall been a good thing for most patients with psychiatric disease but the consequence is that there are many patients living in the community with inadequate mental health resources. That coupled with changes in reimbursement for psychiatric disease has resulted in more patients needing acute psychiatric care than can be accommodated in existing psychiatric hospitals. Between 2009 and 2016, Franklin County (the county that Columbus is in) saw a 157% increase in the number of patients presenting to the emergency departments in the county’s hospitals that needed inpatient psychiatric care.

As a result, psychiatric patients with no place to go fill up emergency room beds. A recent study from Wake Forrest University determined that psychiatric patients wait 3.2 times longer in the emergency room for admission compared to non-psychiatric patients (1,089 minutes versus 340 minutes). As mentioned in a previous blog post, room turnover rates are a key metric in emergency department efficiency and this increase in ED length of stay by the psychiatric “boarders” resulted in a loss of 2.2 room turnovers which equates to a loss of $2,264 to the hospital per psychiatric patient.

At our medical center, Assistant Professor of Psychiatry, Dr. Natalie Lester has a real passion for acute care psychiatry in the emergency department and she has turned that passion into some very tangible improvements in throughput of patients with psychiatric disease in our hospital’s emergency department. In 2013, telepsychiatry was introduced in the ED resulting in a drop in ED arrival time to psychiatric consultation from 14.9 hours to 7.7 hours! This translated to a drop in total ED length of stay from 25.6 hours to 21.8 hours.

In 2014, the Department of Psychiatry opened an 8-bed psychiatric observation unit at our medical center in close proximity to the University Hospital ED (on campus – about 8 miles from our hospital, University Hospital East). That resulted in a temporary reduction of ED psychiatric length of stay by one-third. Since then, however, the length of stay has gone up as the increasing demand for inpatient psychiatric care continues to outstrip supply.

In Central Ohio, there have been new psychiatric hospitals built but they limit their admissions to patients with commercial insurance with the result that there have been essentially no new beds available for patients with Medicaid. This is an enormous problem at our hospital because 65% of our emergency department’s psychiatric patients have Medicaid but only about 13% have commercial insurance. Furthermore, most free-standing psychiatric hospitals do not have the resources to manage patients with concurrent complex medical illness and those that require electroconvulsive therapy, etc.

Dr. Lester found that currently, 10% of the total number of patient care hours in our emergency department was spent managing patients with psychiatric disease. At the current rate of increase of emergency department utilization, by 2019, she projects that 22% of all emergency department hours will be used for care of psychiatric patients. We define the emergency department as being on “psych surg” if > 15% of the ED beds are occupied by psychiatric patients. Between the 2 emergency departments at our medical center, 56% of the hours of the year, one of the EDs is on psych surg. Clearly this is not sustainable nor is our situation unique compared to most other hospitals in the United States. So what can a hospital medical director do?

  1. Advocate for a move away from a traditional model of the ED consulting psychiatry and then admitting for treatment to a model where treatment is started in the ED in order to possibly avoid admission altogether. Larger hospitals should consider creating psychiatric observation units that can specialize in this type of care.
  2. Advocate for our communities to expand the number of inpatient psychiatric hospital beds.
  3. Change reimbursement for inpatient (and outpatient) psychiatric care to expand availability of services.
  4. Consider creation of psychiatric emergency departments in larger communities that can serve as a destination for emergency squads, police-delivered patients, as well as walk-ins thus off-loading regular emergency rooms to focus on medical/surgical problems.
  5. Adopt telepsychiatry programs, especially in smaller hospitals that do not have full-time on-site psychiatry services.

These are very real problems and very real costs that all hospitals and all communities face. We must start planning now for the increase in psychiatric emergency care that is anticipated to affect all of us in the near future.

August 3, 2016

Categories
Emergency Department

The Vital Signs Of The Emergency Department

IMG_0575Is your emergency department sick or is it healthy? If you want to know if a patient is sick, you start
with the vital signs. Emergency departments are the same except that the vital signs are data and you have to know what data you need to know in order to assess the health and efficiency of your ER. At my hospital, every morning, I get an email with the data from the previous day. For me, this is just as important as a patient’s morning vitals are to a hospitalist. Some of the key data elements from our hospitals daily report are:

  1. Number of ER arrivals
  2. Number and percentage of patients who left without being seen
  3. Number and percentage of arrivals who were then admitted
  4. Number and percentage of arrivals who elope
  5. Number of psychiatry consults and length of stay of psychiatry patients
  6. Average time from arrival to first provider (physician, NP, or PA)
  7. Average time from arrival to admission decision
  8. Average time from admission decision to departure from the ER
  9. Average length of stay for patients discharged to home
  10. Overall average length of stay in the ER
  11. Number of emergency squad arrivals
  12. Number of patients in ESI 1-5 categories (ESI is the Emergency Severity Index with 1 being the sickest and 5 being the least sick)
  13. Number of hours of emergency squad diversion

For all of these values, we also have the average daily value over the past 30 days for comparison purposes. It is easy to be overwhelmed by data so you need to know which pieces of data are the most valuable. As the hospital medical director, here are the ones that I scrutinize:

Left without being seen percentage. This is the percentage of patients who show up in your emergency department who leave without being seen by a provider (i.e., a physician, NP, or PA). These are patients who sign in, take a look at how many patients are backed up in the waiting area, and then leave because they don’t want to wait. On the surface, you would think that these are patients with non-acute illnesses, like they think they have a cold or they missed a menstrual period and think they might be pregnant. However, when we have looked at it, a surprising number of these patients are ESI 2 and 3 and really did need to be seen by a provider. If the left-without-being-seen percentage is too high, then your emergency departments healthcare resources are out of alignment with your community’s health care needs. The average ER has about 2.5% of patients who leave without being seen. Although getting to 0% is probably unrealistic for most emergency departments, getting as low as possible is the goal and if your rate is > 2.5%, then you probably have some work to do.

Emergency squad diversion hours. This is the number of hours in a day that emergency squads are “diverted” to other hospitals. Importantly, this does not mean that the hospital is closed and the lay public (and investigative reporters) often confuse this. When an ER goes on diversion, it means that the hospital is not able to easily handle a lot of acutely ill patients and so the squads are diverted to other local hospitals that at that particular time are more able to handle acutely ill patients. In large cities, this works pretty well since hospitals are often just a few miles apart but in a rural area or a one-hospital town, this can result in significant delays in getting patients to a location where they can be managed. Importantly, the hospital will remain open for anyone who does not arrive by emergency squad (for example, walk-in patients) and also generally will remain open for time-limited conditions such as ST elevation myocardial infarctions (STEMIs). There are a lot of reasons why an ER might go on divert: the ER is overwhelmed with patients, multiple patients in cardiac arrest arriving at the hospital ER simultaneously, lack of empty ICU beds to admit critically ill patient to, lack of open regular medical/surgical beds to admit any kind of patients to, unexpected nursing staffing shortages, etc. When the ER goes on divert, not only are you unable to meet your community’s healthcare needs, but since a high percentage of patients arriving by emergency squad end up being admitted, you are turning away potentially lucrative hospital admissions.

Time from arrival to first provider. This tells you how long patients are waiting before they see a doctor (or NP or PA). If this number is too high, then either you don’t have enough providers at certain times of the day, you don’t have enough patient rooms in your ER, or your triage process is not efficient.

Time from arrival to admission decision. This tells you how long it takes your ER providers to decide that a patient needs to be admitted. This metric can be affected by all sorts of things: whether there are enough providers in the ER, how quickly your lab gets blood tests resulted, availability of x-ray and CT scan testing, etc. If this number is too high, then you are going to need to drill down to determine which of the many causes is responsible.

Time from the decision to admit the patient until the patient leaves the ER. This tells you how long it takes to get the patient out of the ER once the ER physician has decided the patient needs to be admitted. Like the last metric, it can be affected by many variables: how quickly a bed in a nursing unit is ready, how efficient your intra-hospital transportation department is, whether your admitting physicians (for example, hospitalists) evaluate patients in the ER before the patient leaves the ER for the nursing unit or whether they see the patient after arrival in the nursing unit, how efficient your admitting department personnel are, etc.

ESI categories. This tells you how sick the patients are that your ER is seeing. In our ER, about three quarters of the patients will have an ESI = 3, followed by ESI 4, ESI 2, and then equally small percentages of ESI 1 & 5. On the other hand, at an ER in a tertiary care hospital or in a trauma hospital, the most common ESI may be 2.  If your ER has too many ESI 4’s and 5’s, then it is likely that your community needs more places to for non-acutely ill patients to be seen such as urgent care facilities, primary care physicians who take add-on same day visits, or “minute clinic” facilities such as exist at many pharmacies.

Room turnover per day. You can calculate this from the number of patients seen in the ER (arrivals per day minus the number who left without being seen) divided by the number of patient rooms in the emergency department. In other words, it is how many patients seen on average in each of room in the emergency department. The higher the number, the more efficiently you are moving patients through the ER. But there is a limit and if the number is too high, then it can be a sign that you need more ER beds. Last year, our room turn number was 6.4, in other words, each room in the ER had 6.4 patients every day. That is a pretty high number so we opened several additional rooms in the ER during the busy time of day with a drop in our room turn number to about 5.2 which is more manageable.

Patient satisfaction score. This is a tough one. Almost by definition, the patients don’t want to be in the ER. Compared to patients who come into the hospital for an elective hip replacement who generally leave pretty happy, about the best you can hope for with ER patients is that they don’t leave too unhappy. So it is hard to have as high of a patient satisfaction score for patients seen in the ER compared to those coming in for elective surgery. Nevertheless, if your ER’s patient satisfaction score is low compared to other hospitals emergency rooms, then you’ll need to drill down to find out why. From purely a business standpoint, an unhappy ER patient pays as well as a happy ER patient but the unhappy ER patient is not going to come back to your hospital when he needs a hip replacement.

It’s hard to treat patients without vital signs and it’s hard to do process improvement in your emergency department without data. But equally important, you have to know what data you need and how to interpret that data.

July 25, 2016