Hospital moves to cure ER ills

Martha’s Vineyard Hospital leaders have taken steps to change emergency room (ER) procedures that led to much patient unhappiness last summer. In large part, the changes are intended to improve the flow of patients through the busy ER, expedite care, and keep patients better informed.

The most immediate effort has been to streamline registration, a process that often contributed to the time ER visitors waited to see a doctor.

A computer in the triage room now allows nurses to input basic patient information so that clinical assessment and treatment can begin immediately. New portable computers allow registration clerks to complete the registration process bedside.

The hospital also plans to add physician assistants (PA) to the staff; PAs are medical professionals commonly used in mainland hospitals to augment doctor-provided care.

The changes follow a blueprint titled “Martha’s Vineyard Hospital Emergency Department Flow Initiative,” new emergency department director Dr. Jeffrey Zack and his team developed and he presented to the hospital board for their approval at a meeting on December 11.

In a recent conversation with The Times, Dr. Zack, who was appointed emergency department director last May, and Tim Walsh, hospital chief executive officer, provided their views of lessons learned last July and August and the changes they expect to make with board support to prepare the ER for another busy summer season.

“We have a chance to do better,” Dr. Zack told The Times. “We were doing a good job in the old place. We gave safe and effective care and I think a lot of people don’t understand how good the care is here compared to some off-Island ERs. But I think we have a really great opportunity to make it even better, safer and faster.”

No breathing room

On June 22, the new $48 million Martha’s Vineyard Hospital opened for business following several years of fundraising. Hospital officials had hoped to open earlier that spring but unexpected delays pushed the date back.

The one-day move from the old ramshackle facility to a new modern building went smooth. But the physical transformation was sharp.

The layout of the old emergency room provided intimacy and little privacy. Ambulances and walk-in patients entered through the same sliding doors that noisily announced an arrival, and they immediately encountered the nurse’s station. In the adjacent waiting room several registration cubicles faced rows of chairs where patients waited to be called.

The new emergency room provides separate entrances for ambulances and walk-in patients. Registration takes place in private rooms separate from the waiting room.

The size of the new ER, as with much of the new building, followed Mass Department of Public Health guidelines that dictate how much room must be allotted to specific areas. There is no question that the new 16-room ER is much larger when compared to the old space, where curtains separated treatment spaces.

On the first day the new ER opened, a total of 64 patients moved through the emergency room. It was the busiest it had been in a long time. And the opening came one week before the start of the Fourth of July weekend.

It soon became apparent that the physical change from the old to the new presented unexpected challenges for patients and ER staff. The timing left little time for adjustments.

A letter to the editor published on July 22, highlighted the unhappiness of one ER visitor that summer.

“I just spent six hours in the ER trying to get my grandson hydrated. It took five hours to get what we needed,” Elizabeth Jones of Vineyard Haven wrote. ” … I understand there were at least five ambulance runs while we were there, understandable chaos with only one doctor in the

Perception issues

“The actual physical move went very smoothly. It went really well,” Dr. Zack said. “What we did not anticipate is some of the perception issues that came up.”

Dr. Zack said the new physical design affected patient flow in unexpected ways and isolated the doctors and nurses.

“We were used to operating in this very tight intimate environment,” he said. “You knew who was coming in, who was there, what they were there for. People would walk through the ER when they came in and you could see how many people were coming in and what they looked like.”

He said the new environment placed a premium on privacy but it came at a cost.

“In the old place patients could see ambulances coming in. They watched patients being brought in and saw nurses and doctors going back and forth,” Dr. Zack said. “Now, if you are in that waiting room you have no idea what is going on and how hard the staff is working to take care of people.”

Dr. Zack said ER patient volumes, the time it took to see a doctor, and the waiting time to discharge did not change appreciably.

“However we saw everybody getting upset and complaining because in their minds it was slower and the perception was that it should be faster and better.”

Mr. Walsh said he knew there was a problem by the end of July. By August he knew people were getting angry. He asked members of his senior management team to spend a shift in the ER.

Mr. Walsh and Dr. Zack acknowledged that not all the anger arose from perception issues. There were problems they said.

Loss of intimacy

“One of the things we learned is that we had a lot of habits in the old place that compensated for being in that environment,” Dr. Zack said. “Those working routines did not work well in the new space.”

The loss of intimacy created problems related to a detachment between patients and staff. For example, Mr. Walsh explained, in the old ER the registration intake clerks sat in the waiting room. In the new ER, the intake clerk uses one of the private rooms to register a patient. The same registration clerks also handle out-patient registration.

The result was a person might walk in, find no one to speak to, and then wait to go through a time-consuming registration process prior to receiving any medical evaluation.

“We dropped the ball,” Mr. Walsh said. “We did not handle the registration process that well.”

There was a further disconnect. “From a clinician’s standpoint, it was triage by sight when people walked into the old ER,” Dr. Zack said. “In the new place you don’t walk through the ER first and the docs lost the opportunity to eyeball people. It worked in the old place but did not transition to the new place, so we knew we needed to create a system of triage. That was one of the things we knew we had to fix and we did.”

Physician heal thyself

In September, hospital administrators, nurses and doctors began work to change the ER model.

Dr. Zack described the effort in terms of two phases: “This is what we’ve got, how can we fix it; what can we do going forward to improve it.

“First we had to figure out what was wrong and then how to fix it, and we realized some of these things could not be changed until it was slower because they involved IT (information technology) and physical changes,” Dr. Zack said. “And none of that could be done in the middle of August when you are getting slammed.”

The blueprint presented in December calls for a concerted effort to triage everyone within 5 minutes of arrival; move the person to an open-staffed treatment room as soon as possible and provide bedside registration. The overall goal: Build in flexibility.

Also, Mr. Walsh said the hospital now allows out-patients scheduled for tests to register by phone. For example, if a primary care doctor orders a CAT scan, the patient can now go directly to radiology and bypass the registration desk.

“It is more predictable and it takes lots of people out of line that were in the ER,” Mr. Walsh said. “We’re getting great feedback.”

Patient first

Under the old model a patient walked in and registered first, a process that could take from five to 30 minutes, or even longer in some cases. The patient then went to the triage room for evaluation and then returned to the waiting room until a doctor was free. If tests were required the wait time was extended.

Dr. Zack explained that someone who walked in at the tail end of four people would be lucky to get through registration in one hour.

“So they’ve been in my ER for an hour and no one has taken care of their problem. So from their perspective, my God, I’ve been here an hour and no one is doing anything for me; and from my perspective I don’t even know they exist or that they’re angry at me.”

It was a problem that needed to be fixed. “What we wanted to do is make this about the patient, not about the billing or other issues,” he said.

The solution was to bring patients straight into the triage room for an initial quick evaluation. A nurse enters basic information into a computer. Tests can be ordered and records accessed without the patient waiting to complete the entire registration process.

That began in November. Dr. Zack said the small change shaved from 20 to 100 minutes and added efficiencies. Now when a doctor sees the patient, he or she has valuable information and does not have to add time to the patient’s visit by ordering tests.

“We’ve utilized that time to do something productive,” he said

Small hospital, big problems

Unlike in a larger hospital, one or two patients can have a dramatic effect on wait times, Mr. Walsh said. For example, on an average day it takes approximately two hours to get treatment.

“However, if one patient comes in and ties Dr. Zack up for one hour you have just added an hour to the rest of the day,” he said. “For the rest of the day everybody is going to wait an extra hour.”

As an example, Dr. Zack said that on one previous Monday there was one doctor on duty and 12 patients arrived between 10 and 11 am.

“You can be the fastest doctor in the world and you cannot avoid a wait,” he said. “That is the ER. People come in when they come in and you have to be able to adjust to that fluctuation. Adjusting to the ER fluctuation was and is the biggest challenge.”

The smaller the hospital the more difficult it is to adjust to that unexpected ebb and flow. Although it was always possible to call in another doctor there was no formal mechanism in place to do that. The blueprint provides a trigger.

When the wait appears to be more than two hours, new protocols now call for an immediate discussion between the medical and nursing supervisors about what can be done to open up patient flow. When needed an additional ER doctor is called.

It is still a work in process, Dr. Zack said. But the goal is to “build in flexibility.”

Phase two

Dr. Zack’s December power point presentation to the hospital board analyzed the ER and provided a prescription for changes.

“Emergency medicine is about motion, keeping things moving forward,” Dr. Zack told The Times.

In a busy medical environment with many moving parts, it helps to have someone responsible for keeping the overall picture in focus. In larger mainland ERs that job falls to a designated charge nurse.

In the old ER there was not one person whose job it was to provide an overview of all ER activity and maintain communication. It was not needed.

The blueprint describes the charge nurse as a “department flow leader,” someone who would move from the triage to the treatment rooms to the waiting room and act as a patient mover and communicator.

Currently, the designated charge nurse also provides clinical care. Ideally, in the summer he or she would be freed up to focus on the overall picture. Mr. Walsh said he is moving toward that goal.

“It comes down to staffing and resources,” Mr. Walsh said.

Hospital emergency rooms are expensive to operate. They are staffed 24/7 and treat every patient who walks in the door.

One challenge is how to address backups that may not be entirely due to emergencies without calling in another doctor. For example, Dr. Zack said, if a man comes in with a large laceration it may require one hour to repair. That hour is pushed onto the other patients waiting in the ER. In that situation it may not be cost-effective to call in an additional doctor.

Dr. Zack said a midlevel provider physician assistant overseen by a doctor could schedule wound rechecks, remove stitches, order tests, write prescriptions, and handle minor complaints.

Each summer the ER patient census rises from about 25 patients per day to 90 to 100, according to the report. To compensate for the influx the hospital hires temporary doctors to augment the full-time staff. Dr. Zack has proposed adding two PAs in place of one temporary doctor.

The hospital is now in the process of hiring one year-round PA and one summer PA, Mr. Walsh said.

The blueprint calls for PAs to staff a “fast track” where patients with minor injuries and complaints would receive treatment. Dr. Zack said PAs can provide follow-up, wound checks and remove sutures.

Among the goals he lists in his new staffing model: more time spent with the patient; improved patient safety and satisfaction.

“We wanted to build a better system so that people feel comfortable coming here, that they feel that they can come in and get efficient great care,” Dr. Zack said. “We want to make sure that this wonderful hospital is utilized for the community that it was built for.”