Parkland Hospital ER Death - More Details

I have a soft spot for Parkland Memorial Hospital. It is a county hospital that sees all-comers regardless of their ability to pay or legal status. I also did an externship there and can say from first hand experience that the ER is amazingly busy and they see about as much trauma as any other hospital in the country.

On September 19th a 58 year-old man died after waiting 19 hours in the emergency room. The event is, of course, tragic and hopefully lessons will be learned. The attached link gives a more detailed description of events, a time-lapse of his wait as well as the coroner's report.

I liked the quote from Dr. Arthur Kellermann from Emory University;

"My hunch is that it happens several times a week in hospitals around the country and it doesn't make the paper," he says. "And that's just completely and totally wrong."

When a clinic tells a patient that they can't be seen for 1-2 weeks what safe guards do you have in place to prevent a disaster? If a 58 year old male called your clinic with abdominal pain how long would he wait? Are they simply instructed to go to the emergency room? Told to call back if symptoms worsen? The lessons reach far beyond ER wait times. It would do all clinics some good to take a look at the effect of wait times on patients.

RATED ER

Another version of a rapid triage system for ER's is reported at a Washington hospital. The patients are classified into three streams with seperate teams and workflows for each team.

Food for thought.

ER Wait Times lowered by Appointments

Can ER wait times be lowered by having appointments? Before someone like Gruntdoc rips me a new one, hear me out. In 1999 I moved out of the big city and started working in some smaller hospitals including an 18 bed, single level hospital in south-western Ontario. One weekend a patient paged to tell me that he had a problem and had called the emergency department and was going to meet the doctor there at 2pm. We do the same thing in our clinic. When a patient is referred for an emergency (pain, infection, facial fracture) we don’t usually tell them to come over and wait, we find the best available time. In fact, Ontario statistics show that the smaller the hospital, the lower the ER wait time.

So why don’t emergency rooms use the same approach to lowering ER wait times? There’s the obvious argument that people seeking care in the ER have, by definition, emergencies which can’t be scheduled. Yeah right. And a Nigerian businessman tells me the cheque’s in the mail. Some ER’s see up to 70% non-emergency cases. And in my experience, another 20% don’t need the rest of the hospital, just the emerg. That leaves 10% that really can’t be scheduled in.

For the usual load of minor cases that need to be seen within 24 hours but not urgently why not schedule them?

Here are the advantages as I see it:
Control – there are ebbs and flows to the day that you can predict (after-school crowd, after-bar crowd, knife & gun club, etc….). More elective patients can be scheduled lighter or heavier during certain times of days.
Patient Satisfaction – even though the total wait may be longer, most of it will be spent at home so their satisfaction will go up. The total wait to the patient may be the same (so there is no additional burden on the system) but the perceived wait will be less and the patient flow in hospital will improve.
Phone Triage – to either divert someone to a walk-in clinic or arrange for a standing order (e.g. for x-rays).

The down side is that the person staffing the phones would have to be expert in scheduling and comfortable following direction regarding which patients need to come right in. There would have to be a process-flow diagram before the patient can be given an appointment to prevent delaying care to a true emergency. I have a nightmare scenario where someone calls for an appointment for chest pain and is stupidly given one 12 hours later. One could make a good argument to have a triage RN on the phone as well.

Technology would have to be heavily relied upon to track patients. There would have to be a means to track “potential” delays in care and keep them low. But with the advent of advanced technology which can schedule, track patient flow, create digital dashboards and balanced scorecards and VoIP phone systems this system is possible to create and make effective..

The experience for our clinic shows that a) mistakes in booking will happen (we’ve booked facial fractures for 2 weeks down the road by accident). Create a system to identify and prevent such errors. b) Even with scheduling our emerg patients still come in during the usual rushes. The emerg managers would have to have significant control of the scheduling process to make it effective c) Patients don’t wait any longer than the rest of our patients once in the door (e.g. in and out in approximately an hour) and they almost all are seen the same day as they are referred.

Just an idea I’m throwing out. I suspect it’s been tried somewhere (and someone will tell me why it didn’t work) and that someone will tell me I’m an idiot. But, unless we try something new the ER wait times will continue to spiral out of control.

Trying to Change Triage

Nurse Dan at Simovative Solutions had a pretty good rant the other day about management trying to decrease ER wait times in triage by bringing patients straight to a room. For those of you not in the medical field, triage is a queuing model where everyone is evaluated (basically first come first serve) for severity of illness by a nurse and usually at the front desk then put into a priority queue based on the severity of their illness. The problem was that management saw a problem, read an article in a magazine (about a smaller rural hospital that tried the solution of straight-to-room triage) then implemented it. Dan wasn’t impressed.

No study, no staff involvement, no goals, just a memo.

This is a typically example of a shot-gun approach to solving a health care wait time problem that rarely works (and if it does you have no idea if it was the change that helped or if it was some other factor). But it’s a great way to introduce the idea of the 4P’s. The 4P’s are from a book called The Toyota Way by Jeff Liker and stand for Philosophy, People, Process and Problem Solving. They are a principle of The Toyota Production system. If Dan’s rant is accurate management missed philosophy and people then took a blind stab at process and problem solving.

It’s management’s job to take a global look at a situation. People in the field are bankrupt of time (especially in a busy ER) and rarely have time for analysis. Dan’s management did the right thing by identifying a problem but it wasn’t framed in quantifiable terms. Rather than: “we want to decrease ER wait times in triage” I think the real goal should have been “we want to decrease the number of people that wait greater than 15 minutes for triage to under XXX / 10,000”. If they choose a six sigma value (a laudable goal) it would equate to 3.4 people per 1,000,000. A more reasonable goal is 3.5 sigma which is 22,700 people per 1,000,000 or 97.7%. In addition, if you use the 5S’s to improve a process, you get a better analysis, plan and employee ownership of the problem.

After setting a goal they could have done an analysis with the people that work triage to identify what they think is causing the problem, come up with a potential solution, implement it, and monitor the “error rate” then change again. This process is called a quality circle.


In my next post I’ll show an example with hard-core numbers about how to develop a process flow map. In a process flow map you diagram patient flow and measure the average time in each step and the amount of variation. As I’ll show in the example it’s usually the amount of variation that is causing the problems with client satisfaction not a subtle change in the average.