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.

Are ER's the Solution to the American Health Care Crisis

Two days ago, Mr. John Goodman, a policy advisor to Senator John McCain commented on a recent report of the number of uninsured Americans'. According to the Dallas News;

'Mr. Goodman, who helped craft Sen. John McCain's health care policy, said anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort.

"So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care. "

"So, there you have it. Voila! Problem solved." '

Which seemed like an odd statement to me. Not that I think a politician wouldn't hide their head in the sand but this seemed too over the top. Luckily the National Center for Policy Analysis released a statement yesterday.

Although 15.3% of Americans do not have health insurance;

"Nearly 18 million of the uninsured lived in households with annual incomes above $50,000 and could likely afford health insurance" and "Up to 14 million uninsured adults and children qualified for government programs in 2004 but had not enrolled".

"In theory, therefore, about 32 million people, or 70 percent of the uninsured, could easily obtain coverage but have chosen to forgo insurance, explains Herrick. That means that about 95 percent of United States residents either have health coverage or access to it. The remaining 5 percent live in households that earn less than $50,000 annually. This group does not qualify for Medicaid and (arguably) earns too little to easily afford expensive family plans costing more than $12,106 per year. A uniform tax credit would go a long way toward helping this group afford coverage."

Which begs the question; can a family living on $50,000 a year really afford insurance at $12,106 a year? Maybe the cost of living is different in Canada than the US but that seems like a very thin margin for housing, food and other necessities of life.

Regardless, the reality is that 15% of people still don't have insurance and even if that number was cut in half are emergency departments still supposed to provide chronic care?

ABC News Reporting ER Wait Times a National Problem

The issue of longer wait times as a result of lack of access to primary care is gaining more publicity. This week ABC News reported on wide spread ER wait times issues due to lack of primary care. Despite the profound differences in US and Canadian models both are suffering from the same problems. Until PCP fees are normalized I don't think we'll see an end to the problem.

Mental Health Waits in the US

The mentally ill face long ER waits in the US with 10% over a day. Aside from the obvious problem, how do beds used for over a day effect ER wait times for other patients.

Long ER Waits result from Hospital Closing

A story about hospital closings in New Jersey. It's interesting that the average wait at one hospital in the ER is 3:45. Undoubtedly, this would not meet the UK ER Wait Time standards.

via Save Muhlenberg

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.

Baltimore Faces ER Overcrowding

Baltimore, home of the famous ShockTrauma institute is facing it's own ER overcrowding crisis. Similiarly to Ontario, alternate levels of care (primary care) are unavailable forcing patients into the ER.

They state ER usuage is increasing. In Ontario the use decreased between 1993 and 2001 (.33 uses per person per year to 0.25) but the transition to more chronic care patients clogged up the ER's.

Ontario Invests $109 Million for ER Wait Times & EMS Delays

As previously reported EMS has been in a no win situation in Ontario (and many other jurisdictions) when arriving at the emergency room. The ER refuses to accept the patient and EMS cannot abandon them. The Ontario government has announced $4.5 million targeted for dedicated nurses to accept patients who arrive by ambulance to ease the EMS pain.

To minimize ER overcrowding money is also being targeted at alternate level care (ALC) to allow chronic care patients in the emergency room to be transferred out and minor injury patients to seek primary care elsewhere.

Ontario's $109 million investment includes:

• $39.5 Million for a Performance Fund targeting Ontario's 23 poorest performing emergency rooms, IT enhancements and coaching teams to enhance hospital efficiency
• $38.5 million for increased home care personal support and homemaking services and enhanced integration between hospitals and Community Care Access Centres
• $22 million in new priority funding for Ontario's 14 Local Health Integration Networks (LHINs) to invest in local solutions to further address ALC pressures
• $4.5 million for dedicated nurses to care for patients who arrive at ERs by ambulance to ease ambulance offload delays
• $4.5 million for new nurse-led outreach teams to provide more care to patients in long-term care homes to avoid transfers to the ER

According to survey studies by ICES scientist Dr. Michael Schull , chronic patients occupying ER beds waiting for ALC are a major cause of ER overcrowding. Interestingly, emergency room physician and nursing staffing had been previously identified as potential causes of overcrowding but this does not seem to feature predominantly in current research or funding.

I was left wondering whether overcrowding correlates strongly to ER wait times, since most ED patients are never admitted. As we found in our own office, more space does not necessarily equate to lower wait times but it is a good first step. Regardless, rather than penalizing hospitals that perform poorly the government is targeting additional funding towards them and offering expert assistance in streamlining patient flow.

Will Extra Funding to Clinics Ease ER Wait Times?

In a bold move Connecticut is spending $798,558 to significantly improve the staffing and hours of clinics to decrease hospital waiting times and add IT infrastructure to allow ER's to move patients to clinics. But, research north of the border shows that the real congestion in emergency rooms is cause by chronic care patients, rather than those who opt for the ER rather than a clinic. According to Dr. Alan Hudson who heads up Ontario's Wait Time Strategy, the problem is that "too many people using the ER and the wrong people using acute-care hospital beds.". To this end Ontario has pledged $700-million to Ontario's ageing at home strategy which is intended to help stop the use of emergency departments by chronic care patients. It will be interesting to see in the coming years if the step by Connecticut will have any siginificant impact on ER wait times of if it's just a drop in the bucket.

EMS in No Win Situation

In a classic no win situation EMS in Edmonton have been forced to station personal at local emergency rooms to care for patients during times of high call volume. In case, you the reader, have not heard of this problem before, EMS will bring patients into the ER during times of high call volume only to find that the emergency will not accept them because it's not safe to do so. In other words, there is not enough beds, space or nurses to accept the patient so the EMS crew can be left waiting for minutes to hours with the patient on the gurney.

With EMS crews tied up in the ER the result is delays to 911 calls and longer response times. In the case of Edmonton they spent only 92 minutes per day with high response times a year ago which ballooned to 4.5 hours this year. Rather than try and change the ER departments, they put crews in the ER to allow the ambulances to get back on the road.

Between 1997-2001 I helped organize the medical teams for the Caribana Parade in Toronto (a retrospective review of the event can be found here). Because of the crowds, EMS response times would quickly become horrific because it took so long for ambulances to get too and from hospitals. To rectify the problem we put a medical tent on site (with excellent effect). It improved service for the patients, relieved the load on the EMS system (because each ambulance could respond to many more calls) and was a blast to work at.

In Edmonton, it's a similar problem except that the slow turn-around for ambulances is because of the delay at the ER. My opinion on this? Congratulations to the EMS chief that had the guts to put crews at the hospital. I suspect passing the patient from one EMS crew to another (especially in an ER) is not without it's legal liability but they're looking at the greater good and doing the best they can with the system. As for the emerg departments, I cannot find fault. To accept a patient that you know you can't monitor carries great risk. On the one hand, they've now transferred the burden of slow response times to the EMS service but on the other hand EMS usually has a greater pool to call on in dire situations (such as neighbouring ambulances and other first responders).

The government could act decisively in this situation with staffing for this specific situation or legislation to protect the ER personnel that accept the patient in a bad situation. Having the staffing, physical space and legal protection to create a non-ambulatory triage area would go a long way to allow ER departments to accept these patients during busy times. The long term answer, unfortunately, is greater long-term beds to get chronic care patients out of the emergency. And that will not be a quick fix. In the mean time, someone from the government needs to look to a better solution other than creating a virtual ambulance in the emergency department.

Why the NHS is failing Wait Times

You’d think that when writing a blog on health care wait times, the interest would come from the countries where wait times are the worst and the population the greatest. In my own mind, I assumed that countries with socialized medicine, and long waits, would top the list of interest (especially the UK) followed far behind by the United States. After all, the US is the home of free market medicine, greater supply than demand and a hospital on every corner; right? So why is my list of readers exactly the opposite? Why don’t the clinicians of the National Health Service (NHS) in the UK seem to either care or be engaged in the issue?



The greatest interest and passion about low ER, surgical and health care wait times is undoubtedly coming from the United States. They care about the technology, the business of health care (practice management), and the impact on patients. At first I thought that it was because so much of the US is on a fee-for-service model and they benefit financially from it. But that is too superficial an explanation. Because, the bulk of health care workers are not compensated on a fee-for-service model (such as the nurses). And if my blog stats are to be believed, they are just as, if not more passionate, than those that stand to benefit from lowering wait times. Nor do I think it's a matter of a fee-for-service system creating greater accountability to the patient. Because, in all of our systems, there is a deeper moral accountability to someone who is suffering. On deeper reflection I think there is much more to it and something that both Health Canada and the NHS should learn from.

The first major meeting I attended about hospital costs was between an outside financial consultant and our surgical service (incidentally the consultant had closed our program when I was a resident and she was a VP of an inner-city hospital). She was amazed that we had little or no “cost awareness”.

She started in on the group of surgeons, “don’t you want to know how much you’re supplies cost?”
We all sat their like scolded school children (or pissed off teenagers – the debates’ still open), until one of the senior orthopods piped up, “No”
“Why not?”
“Because it doesn’t matter.”
“How could it not matter! If you know how much supplies cost and you choose a less expensive option you save the hospital money and it costs you nothing.”
“Because”, he responded, “I’ve been doing this for 25 years and I’ve already been through cost awareness programs. I’ve saved the hospital thousands and you still take my programs’ money away. On the other hand, a colleague costs the hospital tens-of-thousands, and you give him more”
“There’s no logic or control to how the money flows so why should I care? I’d rather just do my job”

That ended the conversation. Let me add, that this is one of the nicest most dedicated community surgeons I’ve had the pleasure of working with. And I’ve heard it from others as well,

“I just wish they’d make the government contact responsible for all the money without any levels of bureaucracy. At least that way, they’d feel some responsibility for what’s happening”. Or from a friend in the NHS when I asked him to pass the word of my blog around,

“Most of the control of patient flow is pretty much out of the hands of the clinicians over here. Not that I do much clinic work, but for the most part, the docs end up just being work horses. We show up to the out-pt [sic] department, get allotted a room for the session and plow through the stack of patients until they are all gone. We don't tend to have our own offices and staff when working in the NHS.”

And with those stories in mind, I think I know why clinicians in the US are so much more passionate about wait times; control. Because in the US, there are very few layers between the purse strings and the patients compared to countries with socialized medicine. The patients’ pay the hospital, and the hospital pays the employees. I am not making a plug for privatization. I believe that in a developed country you should have access to health care no matter your level of income. And, I will leave it to the economists, bureaucrats and politicians that study such things, to determine the most economical model.

But there is a fundamental difference between how clinicians view wait time problems in the US compared to other societies. I think it is a matter of their passion for efficiency. Since efficiency in health care is proportionate to life and death it doesn’t matter what role you play, you need to be passionate about it. But when you loose control it’s difficult to retain the passion. Without it, the managers are reduced to paper pushers and the clinicians to work horses. For there is no truer observation than that “when work, commitment, and pleasure all become one and you reach that deep well where passion lives, nothing is impossible”. So, when our countries reconnect the people that control the money with the patients that need the care, the impossible will happen.

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.

An Example of Zeroing-In on a Workflow Issue

Today I’ll show a hard data example of how to measure workflow and visualize how it can analyzed. I’ve previously described how a new bigger office actually hurt workflow but what was the specific problem? Our office tries to keep the time someone waits during an appointment to 50minutes. But when we moved offices in June 2007 the number of people waiting longer than 50 minutes increased. The number of “errors” (waiting longer than 50min) went from an average of 9% of people to 12.5% (a 39% increase).

To find the problem a patient flow map during consultation was made.



Using data mining, the times between each stage of an appointment could be retrieved for 596 patients. Three different processes could be found in the appointments to analyze the patient flow. The time from when the patient arrived to when they had they’re medical history completed (includes registration and review of medical history – “Arr to MedHx”), the time between when the medical history is reviewed and the doctor completes the consultation (“MedHx to Doc”) and the time between when the doctor completes the consultation and the patient leaves (“Doc to Out”). Whenever doing a process flow map, start globally and if necessary a more detailed analysis can be added. In this process flow map we used four time stamps to create three time frames.


In 2007 Qtr 2 and Qtr 3 there is a spike in the “Average of "Arr to Out"” (total time). Just prior to the move (Qtr 2) it because of an increase in the Average time from arrival to medical history (registration & medical history review) but after the move it’s because of the doctor consultation time.

In the new office the doctors offices are located further from the consultation area (one-short stairwell away but a world apart) so doctors were constantly running down stairs for chart-work (and to surf the net). By adding dictation, phones and internet access in the consultation area the problem seems to be resolving. We could have done more studies to look at times with arrival to registration, registration to xray, xray to medical history, etc… but the possibilities are endless. Always start with a more global view to scan for the problem then drill down as necessary.

For those who are mathematically inclined keep reading. The number of people waiting greater than 50minutes is our error rate and is synonymous with the sigma value. The sigma value went from 3 to 2 which prompted the intervention. When we compare the time before the problem period (2007 Qtr 2 and 3) look at what changed:

Error Rate (% waiting > 50min): Up 39% (9% to 12% of patients)
Mean Wait: Up 10% (from 34 to 37min)
Stdev (standard deviation) of Overall Wait: Up 18% (from 10 to 12min)

But drill down on the two time frames, “Arr to MedHx” and “MedHx to Doc”:
Arrival to Medical History: Mean Wait Up 11% and StDev Up 1%
Medical History to Doc Consult: Mean Wait Up 25% and StDev Up 40%

The take home message is that it is not enough to know the average wait time; you have to know the amount of variation in the wait time as well. In this case, the increase in mean wait was a smaller part of the problem than the increase in variability (of how long it took the doctor). To put it into an ER wait times scenario, a hospital may claim that the average wait from arrival to initial assessment is only up 10% but the variation may be much different. High variability will lead to high error rates quickly whereas it moves the mean up slowly. In ER wait times, the more critical value is how many people are waiting too long for assessment/triage (see CTAS scale for Canadian standards). In our case, the mean was up modestly but the “error rate” was catastrophically elevated by high variability of one segment of the appointment. Luckily, the problem was easily rectified once we realized what was happening.

New Strategy for Crammed ER's

Thunder Bay is in Northern Ontario and is considered a remote area. They have difficulty attracting family doctors and face chronic staffing issues. In order to alleviate ER waiting, the Ministry of Health putting more funding to aging at home and community resources. Apparently a major part of the ER crunch is long term patients taking up beds. It might help with bed issues but I think they'll still have major waits. It'll be interesting to see if it has any significant effect.