Checkout this graphic from a recent Wall Street Journal article (ERs Move to Speed Care; Not Everyone Needs a Bed, Aug 2):
This is based on a survey of people who left ERs without being seen and breaks down how long they waited before bolting. The number of people who leave without being seen has been creeping up in recent years:
The national average of those who leave without being seen—called LWBS—was about 2.7% in 2007-08, according to the most recent government data available. This is up from 1.7% between 1998 and 2006, according to an analysis by Johns Hopkins University researchers. In some areas, as much as a fifth of patients who show up for care end up leaving before they see a doctor. Many of these may go elsewhere for care or end up feeling better, but studies show that as many as half who left without treatment were judged to need immediate medical attention. One study found that 11% of patients required hospitalization within the next week, including some who underwent emergency surgery.
“People who walk out without being seen are a measure of how we are basically failing as a health system in our ability to deliver important care in emergency departments,” says Renee Hsia, assistant professor of emergency medicine at the University of California San Francisco.
Beyond the impact on patient care, having patients walk out also impacts the hospital’s bottom line. According to the article, an ER seeing 50,000 patients per year is out $450,000 if 1% if patients leave.
So what steps are hospitals taking? One possibility is simply better scheduling.
Door to Doc, which includes a model hospitals can use to match staffing levels to peak-demand periods, was developed by Banner Health, a 21-hospital system based in Phoenix, Ariz., with 680,657 ER visits last year. Kevin Roche, program director of process engineering, says that in some months before the program started up to 20% of patients left without being seen and the average time to see a doctor was more than four hours in some hospitals. At Banner Good Samaritan Medical Center, the Door to Doc program cut the rate of patients who left before being seen to 0.5% last winter from 8% in 2007, although the volume of patients in the department rose 4%
Door to Doc has also involved some process redesign (although these are not fleshed out in the article). One program that is explained in a little more detail is call qTrack.
Dr. Guarisco saw the need for a more efficient way move patients through the ER after Hurricane Katrina, when the flagship Ochsner Medical Center’s volume nearly doubled and its left-without-being-seen rate soared to 15%, from a historic rate of about 5%.
His team designed a protocol called qTrack to rely more on providers like physician’s assistants for less-ill patients. Unlike traditional triage, which might take 10 minutes, qTrack has nurses giving a “quick look” evaluation to get basic information in three to five minutes.
Less-ill patients aren’t given a bed, but are offered a recliner or chair in a Continuing Care area, or are sent back to the waiting room to await test results or procedures.
Dr. Guarisco says the changes have effectively doubled capacity in the unit and cut costs per patient visit in half. Average waiting times to see a provider have been slashed to about 33 minutes from hours previously, and the left-without-being-seen rate is below 1%. Ochsner Medical Center also posts ER waiting times at its other facilities near the registration desk. It will preregister patients who don’t have a serious condition at another emergency department “so they can get in line before they leave the one they are in,” says Dr. Guarisco.
This is obviously a very sensible approach. Route patients to cheaper resources if they can be treated by them adequately. Not only does this get lower priority patient into service faster, it keeps doctors and other limited resources available when higher priority patients come in. I once had a consultant speak in service ops class who referred to this as “keep them vertical.”
We have written about posting ER waits before. However, Ochsner Medical Center seems to take it to another level with proactively trying to load balance across facilities. Most hospital systems that post waits seem inclined to let patients make decisions for themselves.