New Emergency Department programs shorten wait times

Norbert von der Groeben

A portion of the emergency department's waiting room is furnished with comfortable treatment chairs and other medical equipment to treat moderately sick or injured patients.

There was no obvious reason why patients flooded Stanford Hospital & Clinic's emergency department on Jan. 25. No major traffic collisions had occurred; the flu wasn't on the rampage, as it was on the East Coast.

But over the course of that day, ED physicians and staff treated 206 people — a 40 percent increase over last year's average daily number of patients and an all-time record. Without Fast Track and Team Triage, that record would not have been possible, said Patrice Callagy, RN, patient care manager in the ED.

Since those two programs were introduced to the ED seven months ago, the median door-to-doctor time has dropped from 45 minutes to 18 minutes. The number of patients who leave without being seen has dropped from the industry average of 2 percent to 0.65 percent.

Stanford's ED is like that of most other hospitals that still offer emergency medicine: It's contending with spiraling growth in demand fueled by powerful forces. The number of people without insurance is steadily increasing, and the number of emergency rooms is steadily decreasing. Nationally, emergency room visits leaped from 114 million in 2003 to 124 million in 2008 to 136 million in 2009. Since Stanford's current ED opened its doors in 1976, visits have risen between 5 and 10 percent each year. It was built for 17,000 patient visits. Last year, it tallied close to 54,000 visits.

In response to this rising tide, the ED has taken steps to improve the efficiency of patient evaluation and treatment, most recently borrowing strategies from the business philosophy of lean management. Lean management aims to eliminate any expenditure of energy or resources that does not create value for customers — or in this case, patients.

ED staff conducted a careful evaluation of their operations, down to the smallest detail. For example, they took a hard look at what paper forms were needed and where they were kept, how patients were informed of delays and what the discharge process required. They used this information to make improvements. The other key step was to analyze the various medical needs of ED patients over a period of time to determine whether changes might be made to speed appropriate care for each type of patient.

First came Team Triage, inaugurated a year ago. Inthe same area as the waiting room, big, bronze-colored letters that spell "TRIAGE NURSE" are affixed to a dividing wall, behind which patients are evaluated by a team of doctors, nurses and ED technicians. Apart from trauma patients brought in by ambulance to receive the highest priority care, everyone who comes into the ED passes through Team Triage's area. Minor injuries are sorted as 4 or 5, the most critical as 1. "Most patients are 3s," said Callagy. "They might have abdominal pain or broken bones." Team Triage also makes it possible for earlier diagnosis of time-sensitive conditions, such as stroke.

Norbert von der Groeben

Behind a dividing wall, a triage team can evaluate patients' conditions as they arrive at the emergency department

An analysis found that 40 percent of the hospital's patients were sick enough to have been admitted through the ED. It also showed that 12 to 13 percent of the ED's patients were 4s and 5s, in no way needing hospitalization. Yet their relatively minor medical issues meant they were waiting the longest, starting with how long it took for them to see a doctor. "We knew we needed dedicated resources," said Grant Lipman, MD, clinical assistant professor of emergency medicine and an ED physician. "The shorter someone stays in the waiting room, the better everyone is. It's common sense and good medicine."

Enter Fast Track, a dedicated team composed of doctors, nurses and ED technicians whose job is to treat, as efficiently as possible, those patients with less severe health problems. "We treat you and let you get on with your life," said Lipman, Fast Track's medical director. "You're the least sick, so we'll treat you the fastest." The median length of stay for Fast Track patients is 65 minutes, well under the original goal of 90 minutes

For 3s whose evaluation and treatment times might take longer because of tests or other requirements, another portion of the ED's waiting room has been partitioned and furnished with comfortable treatment chairs and other basic medical equipment. In this area, clinicians can treat pain, for instance, with intravenous medication. "Treating pain makes a huge difference," said ED physician and Team Triage director Nounou Taleghani.

The benefits of these changes to the ED have been abundant and broad, the emergency medicine team says. Overall, the ED staff is far less stressed, Callagy said, because they can handle the higher patient counts so much more efficiently. And, in surveys returned by discharged patients, the change in wait time is clearly appreciated: The likelihood of Fast Track patients to recommend the ED is in the 99th percentile. The likelihood of patients to recommend the ED overall has risen from the 55th percentile to the 95th percentile since the changes were instituted.

"It's not rocket science," said Marlena Kane, director of business development for patient care resources at Stanford Hospital. "It's bringing the right people together and getting them engaged. We want to make Team Triage and Fast Track permanent parts of the way we do business."

Stanford, Lipman said, "has always been known as a center of excellence for complex specialty care. We want the community to know we're the best and the fastest at medicine's bread and butter, too."