By George Terwilliger, MD

Anybody, Anything, Anytime: Emergency Departments have a tall order: provide excellent care to anybody, all age groups, regardless of ability to pay. An ED (Emergency Department) must be able to handle any type of medical illness or trauma, no matter how severe. And this must be done anytime: days, nights and holidays. We are very good at this, as you would expect. Now, we are trying very hard to deliver that care more efficiently with some innovative and effective improvements.

George Pierce Terwilliger, MD
George Pierce Terwilliger, MD

When you go to the ED, what you really want is to see the doctor or other advanced health care professional (Nurse Practitioner or Physician Assistant) who can diagnose and treat your problem. Having to run the traditional gauntlet of registration, triage, nurse evaluation, and waiting for a room is frustrating. It is customary for the doctor (or other advanced care professional) to wait until all of these processes are completed before trying to see you. However, by that time, other medical urgencies (perhaps worse than yours) may have arisen further delaying your care.

All of these steps are ED standard operating procedure, created years ago to maximize quality and safety. However, they can result in long wait times. The time from arrival to the ED door to being seen by the doctor (or other advanced care provider) is termed the “door to doc time.” Nationally, this time is often a few hours, especially in big cities. Sometimes the long waits are justified by the need to see acute emergencies before less serious issues. You expect that in any ED, a heart attack would be treated immediately, before ankle sprains and earaches.

Another cause of long wait times is unpredictable surges of patients, overwhelming the scheduled staff and outstripping the supply of beds. These surges can happen any time of day and make it impossible to always have enough staff on hand to see every patient immediately. To do so would bankrupt any hospital. Also, there are limits to how quickly staff can care for patients: working too quickly would simply lead to errors and shoddy care. However, our patience wears thin when our loved ones or we are in need of medical care. In times of stress, reasonable explanations for long waits can seem like just excuses.

The Brattleboro area community has been extremely generous and contributed $3,615,122 to allow us to build a new Emergency Department at BMH. This exceptional act of generosity has spurred a detailed reassessment of our operations. We have studied new ways to run ED’s, coming up with a plan that has greatly improved our door to doc times. We are working smarter, not just harder.

A key insight into our research is that we can improve efficiency, as well as quality, by collapsing long series of separate steps into parallel processes:

  • Instead of full registration in the waiting room, only basic information is asked, saving full registration for later. Insurance information can wait until your care is well underway.
  • Our goal is to have you brought directly to your room by the triage nurse with the doctor (or other advanced care provider) and your primary nurse quickly coming in. This team efficiently gathers pertinent medical information together, minimizing the number of times you have to answer the same questions over and over.
  • With our state of the art computer system, tests and medications can be ordered immediately in your room.
  • After the most urgent parts of your evaluation and treatment are underway, folks from registration visit you in your room with a portable computer to complete your check-in process.
  • Your doctor (or other advanced care provider) and your primary nurse will return later to further examine you and gather more details of you medical situation.

We measured our door to doc times before and after implementing the above plan earlier this year. We are pleased to report that we had a 32% reduction in the time from ED arrival to seeing the doctor. This time is currently averaging under half an hour. We believe this has also improved quality.

Other measures to further improve efficiency and quality

  • Analysis of our patient flow data (using our new, state of the art ED computer system) has allowed us to increase staffing during the times most likely to experience surges.
  • Our newly constructed ED has given us 3 additional beds that have reduced the number of patients sitting in the waiting room and our need to use hallway beds during surges.
  • We are increasingly utilizing expert DHMC-employed ED physicians who also work at Cheshire Medical Center in Keene, NH. They are a remarkable group of physicians who bring a wealth of medical knowledge as well as keen insights into how to manage a busy ED.
  • RapidCare: As part of our goal to provide the best possible care, we recently implemented RapidCare. The changes above plus many others form a program designed to provide efficient and quality care for non-critical emergencies, so you can get in and out of the ED as quickly as possible.

George Terwilliger, MD, is the Site Director for the Emergency Department at Brattleboro Memorial Hospital.

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