When Ethel Salzberg, 87, was wheeled into the emergency room in Boston after a recent fall, she'd steeled herself for a long haul in a crowded waiting room. So she was startled to be seen immediately by a nurse who took her vital signs and whisked her into a private room where companions, once banned, were welcome. "My mother-in-law is very nervous," says Dena Salzberg, who brought Ethel in. "For her to have me with her is huge." Salzberg was registered at her bedside and visited by a doctor within 10 minutes.
At Brigham and Women's Hospital, where Salzberg was treated for a dislocated shoulder, the ER patient is now a VIP. Over the past three years, the hospital has totally re-engineered its emergency department to streamline operations. Today median "door to doctor" time is just 12 minutes and patient satisfaction surveys show the score for emergency care has soared from 35 percent to 99 percent. It's a target more hospitals are working toward, in the wake of a 2006 Institute of Medicine critique of emergency care as overwhelmed and fragmented from the rest of the hospital, and as institutions scramble to bring in more business and come to grips with Medicare reimbursement rates now partially tied to patient satisfaction. Most have a fair way to go. The median wait time to be seen in U.S. emergency departments is now 33 minutes, according to the Centers for Disease Control and Prevention. But that means a good many comers still sit and sit and sit.
Online booking. One visible sign of the times is the hospital billboard, strategically placed to announce current ER waits. Inova Health System offers a free app in the iTunes store that provides updates at its 10 emergency centers in Northern Virginia. ER Texting, a Miami company, sells a service that lets consumers send a text to 4ER411, punch in their ZIP code, and find out what to expect at some 235 participating ERs. For $9.99, about half of Tenet Healthcare's 50 hospitals allow patients to view and book available appointments online, waiving the charge if they're not seen within 15 minutes of the time. "Patients can't schedule their emergencies, but they certainly can schedule their urgencies," says Joseph Guarisco, chair of emergency medicine and system chief of emergency services at Ochsner Health System, the largest hospital system in Louisiana.
The marketing push is controversial. "If it's an emergency, minutes count," says Lewis Goldfrank, director of emergency medicine at New York University-Bellevue Hospital Center. "If it's not an emergency and people have time to schedule, then it's outpatient care at a higher cost, and allows EDs that aren't busy to replace primary care."
But the main point of rethinking emergency department design is to deliver better medicine, experts say. Similarly to Brigham and Women's, where nurses now greet patients as soon as they walk in the door, Vanderbilt and Penn State post doctors at the ER entrance to get patients seen and testing started. The Cleveland Clinic uses a "split flow" model of triage that separates the acutely ill from less sick patients upon arrival, not to make the latter wait, but to put them on a separate track where they are cared for and released without being put in beds. Sicker people are sent directly to a bed, and the critically ill are treated immediately. Ochsner hospitals have added more providers during certain hours when the less acute illnesses and injuries tend to come in. Registration is increasingly taking place after triage. To avoid hospitalization whenever possible, some facilities have added an observation or short-stay unit where patients can be monitored for up to 24 hours and then often released.
And just as it's been accepted that children's smaller size and immature systems require specialized emergency care, some hospitals now boast a separate ED unit where geriatric patients can be comfortable and feel safe. At Holy Cross Hospital in Silver Spring, Md., whose separate geriatric area opened in 2008, for example, floors are dull to prevent falls, lighting can be moderated to mimic natural daylight changes to avoid confusion, wall colors are soothing, mattresses are extra thick, and phones and clocks have large numbers.
Clear communication is a key customer service goal, too. "Our challenge is to continually update the patient so that at the end of the visit, she doesn't feel she's been stuck in a corner. And we've got to teach this kind of language to residents, nurses, technicians, and everyone else involved," says Peter Hill, associate professor of emergency medicine and vice chair of clinical affairs at Johns Hopkins Hospital in Baltimore. Hopkins's new emergency department has only private rooms, each with a PC, allowing doctors to more easily document and share information with patients.
Prompt briefing. "When I've had to deal with other emergency situations, I had to find out who was in charge and whether that person was available to talk to me. Here, they came to find me," says Ishmael Rivera, a retired New York City firefighter whose son Jeremy recently tore open his shin to the bone in a fall at school and was taken to New York-Presbyterian's Morgan Stanley Children's Hospital. When Dad rushed in, staffers were waiting to tell him what the damage was, who was treating Jeremy, and what needed to be done—and they had the boy smiling and chattering. "I loved that they were playing with him, that they liked him and he liked them, and that the doctors were quick, aggressive, and top-notch," Rivera says. "And I was surprised they engaged in so much conversation with us."
A huge part of perfecting emergency care, of course, involves coordinating rapidly and seamlessly with other hospital departments. It was that sort of "quick action" that saved her, says Joan Hampton of Charlotte, N.C., who suffered a severe stroke a year ago at age 45 and was taken by ambulance to Carolinas Medical Center. An emergency team immediately assessed her situation and paged the hospital's stroke team. The team, including an emergency physician, stroke neurologist, radiologist, nurses, and lab technicians, rushed to the ED and evaluated her, and stroke neurologist Phaniraj Iyengar called for a dose of the clotbuster tPA. The drug, effective only if administered within a few hours of a stroke, opened the blockage completely, and Hampton went home in three days with virtually no damage. At the Mayo Clinic, mandatory monthly training puts multidisciplinary trauma team members from around the hospital through their paces using simulations; each member learns to perform assigned roles, to communicate in a common language, to listen, and to resolve conflict on the spot.
"The potential for disorganization would have been great had we not practiced," says Beth Ballinger, an acute care trauma surgeon at Mayo, recalling a day three years ago, shortly after the training started, when teenage twins were brought in near death after a car accident—a horrible head-on collision with each other. The team, which Ballinger oversaw, included ED attending physician Annie Sadosty, nurses, a respiratory therapist, resident physicians, a pharmacist, and others, and "worked like a finely tuned orchestra," Sadosty says. The team resuscitated and stabilized both twins.