Even ERs need to be run like a business

CEDAR RAPIDS - To hear Ryan Sundermann, running the emergency department of a big hospital in some ways is not that different from any other business that has clients - people, trucks, ships, packages - coming in and clients going out.

“Once the rooms are full, it's all about throughput and moving patients through the department,” said Sundermann, St. Luke's Emergency Department medical director. “From 11 a.m. to 11 p.m., we staff to support every single one of our 34 rooms, and we rarely have any sitting open after 11 a.m.

“Once the rooms are full for the day, it works like a restaurant. You expect to get in without reservations, but on a Friday night, you're going to be standing in line for an hour.”

In extreme-wait situations, Sundermann said the department can call in an extra doctor who will see patients in the front triage area to help move people out of the ER.

It's hard to standardize in a business where nothing is ever the same. While St. Luke's Emergency Department staff members are able to recognize some patterns and trends, they still never know what they're going to face each day.

The St. Luke's ER sees, on average, between 153 and 156 patients daily - it saw 52,000 patients last year.

And with every person who walks through the door, Sundermann said it's a balancing act for staff members who are trying to be efficient with each patient's time and money, yet still provide good patient care.

“From a risk-management perspective, the more tests I order for a patient, the more problems we can rule out. But the fewer tests I order, the faster and more cost-effective it is for the patient,” he said.

Even the amount of time physicians spend with patients is all about finding the right balance.

“The more time you spend, the more the patient will probably appreciate it. But the person waiting behind them doesn't,” Sundermann noted.

And because each patient, situation and physician is different, there are no rules in terms of how short or long a visit should be.

STAFFING LEVELS

To provide adequate staffing, St. Luke's adheres to “fixed staffing,” in which time of day dictates number of employees.

St. Luke's Emergency Services Director Sandi McIntosh says the emergency room is typically slow in the morning. But by 11 a.m., its 34 beds are filling up, and more staff members are added at that time.

The department then stays busy until around 11 p.m.

At maximum staffing levels, there are 25 caregivers in the emergency department - nurses, ward secretaries, paramedics and emergency department technicians. In addition, there is a phlebotomist and four physicians on staff.

Due to the partnership between St. Luke's and the University of Iowa Hospitals & Clinics' emergency medicine program, there also may be a resident or a few students on hand.

The emergency room typically is busiest from Friday through Monday. Nice weather - brings in accidents related to boats, motorcycles and bikes - and bad weather - involving snow and ice - both increase visits as well.

Seasonal surges partially depend on when the flu hits, McIntosh said, which could be anywhere from December to March. Or it could be like what happened this year: The department planned for influenza season, and nothing ever happened.

The emergency room didn't see an increase in visits due to flu, Sundermann said.

The emergency department works closely with St. Luke's radiology, pharmacy, laboratory and cardiology departments for staffing, as well.

“The ER can handle radiology capability for what we call our ‘plain films,' which are basic chest X-rays or X-rays for things like a potential broken ankle,” McIntosh said.

If a CT scan or MRI is necessary, the patient is taken out of the department.

In big trauma events, the emergency department can put out a hospitalwide call for more nurses.

“Not everyone is comfortable coming to the emergency department,” McIntosh said, “so we may pull the supervisors or practice nurses out to the floor.”

The ER also can do blast messaging through the hospital's emergency command center to send a call out to staff members simultaneously.

“We may send a message that says, ‘Bus accident with potential 20 victims. Can you come in?' We wait to get responses back and then start planning,” McIntosh says.

MANAGING SUPPLIES,

MEASURING DATA

Medication in the ER is dispensed through three Pyxis stations. The nurse enters information there about the patient and the medication needed, and the Pyxis station dispenses the medication for that patient.

It also tracking how much is left.

These medication dispensing systems are managed and replenished by the St. Luke's pharmacy. In true disasters, McIntosh said they also can call the pharmacy to bring down additional medication.

All medical equipment, such as IV tubing and catheters, is tracked through an electronic management system. Each item taken from the supply distribution area is scanned on its way out the door.

Once a particular item dwindles down to a certain quantity, a notice goes out for it to be refilled.

Sundermann and McIntosh spend lots of time measuring and quantifying emergency room metrics.

Some of this data is tracked due to requirements from the Centers for Medicare and Medicaid. Other information is tracked because of department interest.

Sundermann also examines data such as LWOBS (patients who leave without being seen).

“The gold standard is having an LWOBS rate of less than 5 or 6 percent, and we're at about 0.2 percent,” he said.

He also measures the amount of time it takes for a patient to see a doctor once they come through the ER doors, and how long it takes for a patient to be admitted or discharged.

The average wait time for a patient in the St. Luke's ER is about eight minutes.

Things such as time-to-EKG for patients with chest pain and time-to-antibiotics for pneumonia patients are tracked as well.

Sundermann reviews any cases where patients didn't receive medication or treatment in the appropriate amount of time.

On June 2, the St. Luke's emergency room, along with the rest of the hospital, will move from paper records to electronic medical records.

“This switch will give us the ability to track these times a lot easier,” McIntosh noted. “We will be able to query different reports that already exist in the system.”

Although Sundermann is confident that the software will pay off in terms of increased safety, secure medication administration, and readily available patient information, he estimated that it will decrease patient throughput by 50 percent.

“Instead of making people wait longer in the emergency room, we're going to increase our staff by 50 percent temporarily,” he said.