The Emergency Room (ER) is a dangerous place to be, and the less time a patient spends in one, the better their chances of an optimal outcome.
This is a simple unpleasant fact, and one reason is a simple truism – people who really need to be in the ER tend to be very ill and if you are one of them, your odds are already sub-optimal.
Other than the rare hypochondriac with Munchausen’s syndrome, most patients in the ER are not in a good way – otherwise they would have fixed it themselves or gone to their general practitioner.
The other reason is both more sinister and complex: ERs tend to get crowded, chaotic, and triaged. The chaos is a result of a combination of crowding, acuity, variation, and stressed processes. Many ER patients really should be treated by a primary care physician, but go to the ER instead because they lack health insurance, don’t know how to gauge their condition, or their primary care provider is not open after hours or on weekends. The ER increasingly supports primary care by performing complex diagnostic workups not provided by primary care facilities, handling primary care overflow, and after hours care. (1)
The fact that ER triage’s patients is a frank (and normal) admission that demand has outstripped supply of services, but ER crowding is mainly a function of idiot politicians and a Gordian knot of infrastructure, policies, processes, technology, and people.
Let’s deal with the simplest but most unappetizing part first
Politicians are those kinds of people who are vaguely of the opinion that laws can reduce the duration of gestation, change the behavior of pathogens, or turn aside hurricanes, typhoons, and tornadoes. I am not sure if this is the result of repeated head injuries on their part, bad genes, or just a lack of scientific training. The problem is that they will enact silly laws to satisfy donors, and these laws will tend to cut funding to primary care, education, nutrition, environment, safety, and a host of other epidemiological causes of injury, disease, and ill health. This not only increases the burden of sickness in the net number of patients, but also means that they will tend to have more serious health incidents, not address illness early on, and present in greater numbers, with more complex conditions, more often than would be the case in the null hypothesis in which there was no stupid politician making these laws.
Simply put, politicians as a class are a health hazard, and sadly, there is no cure for them.
Infrastructure and policies
Somewhat caused by idiot politicians, a sub-optimal infrastructure is often the result of policies that shape themselves to the laws that exist (see above).
Often the policies serve people with money rather than those with need, and as a result the infrastructure caters to heroic and epic conditions rather than those that cause the most harm and suffering to patients. This is somewhat because the people who get sickest and sicker more often tend to live lives that do this to them. They live in places that are more dangerous, have work that is more dangerous, have less education, nutrition, and access to primary care than the wealthier members of society. Low Socio Economic Status (SES) is generally speaking, also a health hazard.
As an example, let’s look at a very fancy cardiac unit, a world famous one.
The first successful human to human heart transplant was carried out by the pioneering surgeon, Dr. Chris Barnard at Groote Schuur hospital, in South Africa.
That’s right, not the US nor the UK or France, but South Africa.
In 2001, there were serious moves by the Western Cape government to close the transplant unit, and in the subsequent public and international uproar, one of those involved in the considerations made a rude, surprising, and very accurate argument. South Africa simply couldn’t afford a fancy 1st world cardiac unit serving mainly privileged white men who tended to have long histories of medical self-neglect as the result of over indulgence, when at the same time, thousands of low SES people were dying of entirely curable and preventable diseases like Tuberculosis. During the various brawls over the unit’s fate, the uncomfortable fact was that although the cardiac unit was a heroic and epic institution, it was far less clear if this was the best use of available resources. For every life saved by heroic attempts in the transplant unit, at least an order of magnitude more died because those funds and expertise were not being applied to the things that were killing far more people in South Africa.
Healthcare is often brutal in this way, and the example perhaps exemplifies how the diseases of influential people are more represented in the policies, and thus the infrastructure of a healthcare system than one might notice at first glance. Policies often translate into more and sicker people coming to the ER, and also less funding to address both the causes of the illness and technology and resources to address them.
Processes, Technologies, People
ER is a compression zone in the flow of patients, since many routes lead into ER, and frequently the wisest course when in doubt over severity and acuity of a condition, is to process them through the ER just in case the quietly seated patient quietly dies because nobody took a really good look with the right level of technology and expertise.
All clinician roles are stressful; let that be said before I draw the ire of opticians, dentists, and dermatologists. ER clinicians however are right up there with the highest stress roles in healthcare. Although it must be admitted that ER clinicians generally get to see better outcomes than some specialties, ER clinicians are usually presented with life in its raw state. Torn flesh, broken bones, and mangled people, some still with the smell of gasoline and tire rubber on their bodies, the smudges of nitrocellulose propellant from gunshot wounds on their skin, and lots of vomit, blood, and tears. ER departments are not restful, tranquil, or serene, and no amount of feng shui, fragrance sticks, or furnishings can change that. ER departments have to sort people rapidly into categories and actions to be taken, often in exact opposite order to instinct. Quiet and blue takes precedence over bleeding and screaming, necks take precedence over hands, clear fluids over blood in the ear.
As a result, ER departments have an urgent need to have supporting technologies such as ED Patient Tracking Systems and Electronic Health Records (EHR), that can remember and track patients that might easily get lost or forgotten, and whose history will be collected accurately and quickly as they transition from the ambulance to the first-look nurse, then triage team, the nurse, perhaps more than a few doctors, specialty care, radiology, laboratory, and yes, accounts. Have they seen this patient before, are there allergies or prior conditions to consider, are they already taking any medications?
However just having an EHR system does nothing unless there is an underlying workflow, and the EHR integrates perfectly with that workflow.
ER workflow is both physical and virtual, and it comprises rules, procedures, activities, equipment, spaces, places, and people. Although some of the people can switch roles in an instant, they are deployed according to a process, licensure, and how the ER facility is physically structured. The very first person must rapidly assess where the patient most needs to go at that instant in order to get them to the right level of care the fastest, and to maximize the use of the very expensive and scarce resources available. The resuscitation team should receive the person with the cardiac arrest; the trauma team gets the one with the bones coming out of the wound, and so on. No sense in blocking the resuscitation bed with the patient with the broken arm. The workflow has priorities, and activities that have primary and secondary actors, and various technologies including equipment, medical gases and fluids, medications, and consumables such as needles, gloves, and dressings.
In figure 1 the fundamental structures of activities within a workflow are shown for typical industrial or business settings (2), but these map directly to their medical counterparts. Tools relate to equipment and instruments, materials to medications, fluids, and consumables, while utilities relate to medical gases, suction, irrigation, and electrical power.
Figure 1. Workflow activity substructures
The implication of workflow is that knowledge is applied to the activities by actors in relation to the tasks they carry out and the requisites they use in doing so. As such to have a functional workflow that is supported by an EHR, the ER also needs to consider who knows what and how they will best come by this knowledge in order to apply it effectively at the point of care. The application of knowledge management principles to ER workflow expands this as illustrated in figure 2.
Figure 2. Knowledge Sources
All things being equal, the ER staff, deployed in space and sequence in a carefully monitored and calculated fashion will quickly identify urgency and action to stabilize, treat, and often admit patients with the maximum efficiency, because in illness, time counts.
However, even a perfect ER, operating at 100% efficiency, will swiftly overcrowd unless the patients can be routed to the next appropriate level of care as efficiently. Whether the next point of care is the patient’s home, their local hospital, or Intensive Care (ICU), the time it takes to process the necessary documentation and route them is not infinitely small, and results in backlog and patients piling up in holding areas in and around ER, and people die in these interstices of care.
The workflow thus needs to integrate with care beyond the ER, so that patients can be drawn off to the next point of care at least as fast as they are processed by ER, and this is where the integration of EHR across the institution comes into play. The workflows at the perimeter of ER can only effectively integrate with those of other services and points of care if the EHR enables seamless transition.
An example of this is the bed management system for inpatient registration. An ER patient that requires definitive care as an inpatient can only be transported to a ward if there is an open bed suitable for the level of care required. To achieve this, the ER clerk must be able to see with great reliability which wards have a currently open and clean bed that has the right associated services, technologies, and level of care. A patient requiring 24hr surveillance may require a telemetry bed, patients with mental health conditions may require special services, and fall-risk patients, and infectious patients have still other bed and location requirements. To complicate matters, ward configurations change, policies changes, and new medical norms arise, requiring the systems and the people to adapt smoothly to changes.
Reflecting on figure 2 one can usefully ask how the ER clerk would know what the current policies are with regard to the patient needs and available beds. The answer is that it will be a combination of embedding the knowledge in the EHR, recruiting people with the right prior application and hospital knowledge, training on the EHR and the policies, and job aids that are either embedded in the EHR or available in conjunction with it.
Throughout the process from registration to discharge, the integrity of the patient’s record must track smoothly across transitions and locations of care, including follow-up and outpatient care.
Integration of workflow, EHR, and knowledge management methods can provide significant improvements in patient flow management in a hospital, and this can be seen in what is perhaps the starkest situation- the ER. Workflow ensures that the right things are occurring with the right actors and at the right time, while EHR avoids medical mistakes by tracking the patient and their health throughout the system. Knowledge management asks the important question of how all the actors know how to do what they are expected to do. This applies to all the actors involved, whether they are clinicians, administrative staff, the patients themselves, or those that care for them.
Acknowledgement: For his invaluable input on ED Tracking, ER operations, and crowding, special thanks are due to “Mr. BMS” Hub Freeman, MSA, RN, Nurse Executive – BC, Clinical Director for Systems Efficiency and Flow Improvement, Veterans Health Administration
1. Hospital Emergency Department Use, Importance Rises in U.S. Health Care System. Hospital Emergency Department Use, Importance Rises in U.S. Health Care System. RAND May 2013.
2. Loxton, Matthew. Knowledge Auditing: An Activity-Based Method for Organisational Success. s.l. : Ark Group, 2013. ISBN: 1783580755.
Matthew Loxton is a certified Knowledge Management practitioner, and is a peer reviewer for the Journal of Knowledge Management Research & Practice. Matthew works at WBB as a senior analyst applying KM principles to Health IT implementation. Matthew holds a Master’s degree in Knowledge Management from the University of Canberra, and provides pro-bono consulting in Knowledge Management and IT Governance to various medical institutions.