DeMerger to be official April 1
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Home Care services to operate separately
Many physicians who interact with Stanford's Emergency Department (ED) begin to view it over time with mixed emotion. On the one hand, the department provides a service of huge significance to us as physicians, to our patients, to the hospital, and to the community. On the other hand, it is a domain with many opportunities for frustrations and dissatisfaction, both from the standpoint of caregivers and patients.
In February, Bob Norris, the head of the Emergency Department, addressed the Deputy Chiefs and Medical Staff Task Force, where he shared some useful information and insights about the functioning of the department.
To begin to understand the complexities involved, some simple statistics are instructive. Last year, there were some 37,000 visits to Stanford's ED, including 1,300 major traumas. (Stanford is a designated Level 1 Trauma Center for major portions of both San Mateo and Santa Clara counties, although trauma cases are often transported here from farther away.)
Approximately 20 percent of hospital patients seen in the ED last year required hospital admission, with 12 percent of these admitted to an ICU. In spite of this large volume, Bob Norris told us that the ED was never closed to trauma and was closed for medical patients less than 1 percent of the time.
The inherent difficulties in managing such a large system are compounded by several factors. First, the ED now functions under rules imposed by the Emergency Medical Treatment and Active Labor Act, which prohibits the department from asking questions about the financial status of patients until they have had a complete medical screening, which typically translates into a full evaluation, including laboratory and radiographic studies. Not only does this regulation increase the amount of uncompensated care but it also leads to ED evaluations of individuals who might be better assessed in other settings. Second, in our local environment, with skyrocketing costs of living, there is an increasing problem of retaining qualified nursing personnel and support staff. Third, Stanford is a teaching institution; over-utilization of resources in patient evaluation is an inherent problem in medical training, and the ED is no exception.
Because of the challenges, it is understandable, though certainly not desirable, that our patients may experience long waits in the ED or that we have problems trying to manage their care in that setting. What remedies are needed and what can we realistically expect? First and foremost, we should return to one of medicine's most fundamental principles: A culture of respect and communication needs to be fostered among referring physicians, caregivers and patients alike. It is amazing how one's experience with the Emergency Department depends on the character of the initial interaction with personnel there. Notwithstanding the myriad pressures that exist in the ED, we can do a great deal to control the environment there simply by paying attention to the way in which we communicate with each other.
Bob Norris has developed some guidelines that may improve communication between the ED attending physicians and patients' primary doctors.
The ED will attempt to keep the primary care physician (PCP) or other referring physician "in the loop" by having the ED clerks immediately call the physician's office or clinic when the patient registers for evaluation. Upon learning that a patient is in the ED, a PCP can decide whether or not he/she wishes to discuss the plans for evaluation with the ED physician team. If so, a simple call can be made to the ED attending's portable phone, (650) 724-2240. If not, the PCP can await a call from the team following the evaluation of the patient. The ED physicians should be touching base with PCPs on all but the most trivial cases.
From the other side, Bob requests that those of us who have important information regarding a patient they are referring to the ED communicate directly with one of the attending physicians, rather than to a nurse or resident. Hopefully, this direct line of communication will reduce errors in transfer of information. Again, the ED attending's portable phone can be called. If the line is busy, the call will roll over to the main ED desk and the clerk will page the ED attending.
Within the ED itself, plans are under way to install a new electronic system for tracking patients and data. This technology is intended to streamline the process of following patients once they have entered for evaluation. Ultimately, it should speed their movement through the department.
While these proposals are intended to help within the existing ED framework, several other issues are being examined to address the basic structure of the department. In the near future, the physical space itself will be re-engineered and most likely expanded. Major considerations in the planning will include the need to create a more up-to-date trauma room with better imaging capacity, an effort to provide designated space for pediatric evaluations, and possibly the development of a separate urgent care facility.
I am particularly eager to see this last concept realized. Those of us who have used the Palo Alto Medical Foundation's Urgent Care Center recognize how valuable it is. Many of us are convinced that a separate area for lower acuity problems would greatly enhance the overall functioning of the department.
The creative, constructive concepts that Bob Norris and his staff have developed will, I'm sure, benefit from our ongoing input. As with so many other issues at Stanford, we do have the potential to influence outcomes, but we must be willing to make the effort to contribute. You can reach Bob at (650) 725-9445 or bob.norris@leland.stanford.edu. He invites your comments and welcomes your support.
