Restructuring the ER
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GWEN IFILL: Susan Dentzer of our health unit has the emergency room story. The unit is a partnership with the Robert Wood Johnson Foundation.
SUSAN DENTZER: Boston, Massachusetts: famous for that long ago tea party in this harbor, for those champion Red Sox. Less well known to the general public — but a fact-of-life in health care circles — are the city’s overcrowded hospital emergency departments.
This one, at Boston Medical Center, is the busiest emergency department in New England, with 128,000 patients a year.
DR. NIELS RATHLEV: I think what we’re going to do is look at your EKG.
SUSAN DENTZER: Dr. Niels Rathlev, vice chair of the Emergency Department, or ED, says it’s one of many Boston emergency rooms that frequently go on “diversion.”
DR. NIELS RATHLEV: Well, diversion means that all of our acute care bays are full and at that point we make a decision that we’re unable to care for yet another sick patient that’s brought in by the ambulance services. We then notify the City of Boston Emergency Medical Services and inform them that we cannot accept any more ambulances.
SUSAN DENTZER: The diversion problem is pervasive here in Massachusetts — and it’s getting worse. State figures show that the number of hours Massachusetts hospitals go on diversion has risen about 50 percent in the past two years. There have been no studies to demonstrate the effects. But officials think the problem is almost certainly bad for patients — and could be causing avoidable deaths.
VOICE ON LOUDSPEAKER FROM ED: Could I have a medical worker to the trauma room, please? Medical worker to trauma.
SPOKESPERSON: I need a bed for this young lady over there.
SUSAN DENTZER: Diversion isn’t just a local problem, either. Studies show that three in five of the nation’s emergency departments, or ED’s, are full or over capacity — and more than a third regularly go on diversion.
The problem stems in part from a growing chronically ill population — and rising numbers of uninsured patients crowding the ED. But some critics say hospital practices are also to blame.
So Boston Medical Center called on this man, Eugene Litvak.
EUGENE LITVAK: Now, you manage to have a high sense of some yet significant increase in patient volume.
SUSAN DENTZER: Litvak is an industrial efficiency expert from, of all places, the former Soviet Union. Before emigrating to the U.S. in 1988, he worked at the then-Soviet Ministry of Transportation. There, he helped to streamline building of the nation’s railroads.
When Litvak came to the U.S., he turned his sights on health care — against the advice of his American scientist friends.
EUGENE LITVAK: People suggested the airline industry, transportation, banking, many, many other industries. They were uniform, however, in suggesting that I never go to the healthcare because they said that the healthcare system is not interested in improving efficiency. So I was very much surprised that probably the biggest industry in the world does not apply the operation management tools that every single other industry is applying.
SUSAN DENTZER: But Litvak was eager for a challenge, so he became director of a program in healthcare management at Boston University. After consulting with a number of U.S. hospitals, he concluded his friends had been right.
EUGENE LITVAK: I was extremely impressed with the level of clinical knowledge and the clinical level of the healthcare delivery here, and even more surprising was the fact that it has been accompanied with an absolutely inefficient system.
SUSAN DENTZER: At Boston Medical Center, Litvak set to work figuring out the causes of the diversion problem. His work there was funded through a grant by the Robert Wood Johnson Foundation, which also provides financial support to the NewsHour’s health unit.
Litvak first looked at all the ways patients were flowing into and through Boston Medical Center. As is typical in hospitals, many seriously ill patients came in through the emergency department. Once treated and stabilized, many would then be transferred to a bed on the general floor. Other patients would come into the hospital’s operating rooms for scheduled or elective surgeries, such as heart bypass operations. If they needed to recover afterward, they’d be transferred to beds on the floor, too. Based on the data he reviewed, Litvak quickly rejected one hypothesis: That the emergency department was being flooded with unpredictable surges of seriously ill patients. In fact, says Litvak, those numbers were steady.
SUSAN DENTZER: So the flow into the emergency department of accident victims, people with gunshot wounds, people with heart attacks — all of that was predictable?
EUGENE LITVAK: That’s correct. Surprisingly, our Mother Nature is more predictable than our actions.
SUSAN DENTZER: Instead, Litvak’s analysis showed the ED bottleneck started here in the hospital’s operating rooms. Those scheduled surgeries were mostly being done on Tuesdays, Wednesdays and Thursdays. That was so surgeons could devote other weekdays to scientific conferences or to seeing patients in their offices.
Litvak says a basic principle of industrial engineering is that bunching up anything this way — including surgeries — is inefficient. A better way is to smooth out the flow. He demonstrated that by an analogy to Boston area traffic.
EUGENE LITVAK: Let’s look at those cars across the river on Memorial Drive. You can see that those cars are driving more or less smoothly, with a similar speed. So when your cars are distributed more or less evenly, then you can get more cars through the road.
SUSAN DENTZER: But the surgery patients at Boston Medical clearly weren’t flowing smoothly — they were being bunched up on just a few weekdays. That led to choke points on those days throughout the hospital.
One was here in the so-called step-down unit, where patients are brought after surgery if they need extensive monitoring.
Janet Gorman was the unit’s nurse manager.
JANET GORMAN: Certain days of the week there would be a bottleneck. There would be patients in the surgical intensive care as well as the recovery room, fighting for the same beds, because it is such a small unit and they were doing so many hearts a day and so many cases that needed the step-down unit, they were both fighting for the same beds. So on those days of the week it was chaotic here.
SUSAN DENTZER: And on those chaotic days, nurses like Gorman racked up dozens of stressful hours of overtime. What’s more, amid the scramble for available beds, Emergency Department patients who also needed to be admitted to a bed usually lost out.
EUGENE LITVAK: There is no bed, and the patient in the Emergency Department became what we call a border. She is sitting in the ED, waiting for a bed upstairs on the floor or in the ICU. In the meantime, this patient is occupying the bed in the ED, so other patients who come into the ED, they cannot get in.
SUSAN DENTZER: That’s what led to diversions. And at the other extreme, when patients coming into the Emergency Department needed immediate surgery, scheduled surgeries on other patients were frequently canceled.
Heart surgeon Dr. Oz Shapira says these so-called “surgical bumps” made for hundreds of unhappy elective surgery patients.
DR. OZ SHAPIRA: Just imagine you are a patient, you’re scheduled to have an open heart surgery or a vascular procedure on your leg on or your blood vessel in your belly. And you’re waiting for this operation for a month, finally, or even just a week. Finally, your day has come, you’re coming into the hospital, change to your gown, and then all of a sudden you’re being told, “Sorry, we can’t do your operation. You’re being bumped for an emergency case, for an urgent case.”
SUSAN DENTZER: Fixing these problems meant eliminating the causes of the bottlenecks.
So for starters, scheduled surgeries were spread out over the week. Heart surgeon Shapira shifted his office hours by one day, to Thursday, to free up Fridays for operations. Among other changes, nurse Janet Gorman was put in charge of a new system, coordinating patient flow through the entire hospital.
JANET GORMAN: The surgical intensive care unit, there’s two patients ready to go in, so I’m making sure they have their beds.
SUSAN DENTZER: The results were dramatic. In the ED, average waiting time and diversion hours fell.
DR. NIELS RATHLEV: In 2001, we had over 700 hours a year of ambulance diversion. We dramatically decreased this number by about 40 percent. This year we project that we’ll have about 250 hours of diversion, which is down about 12 percent since last year.
SUSAN DENTZER: Surgical bumps also plummeted, falling from 334 in one period of 2003 to just three in a comparable period the following year. The changes also saved money — and improved nursing morale — by sharply reducing costly nursing overtime in the beleaguered step-down unit.
JANET GORMAN: You look back and say, “Why did we ever live with it?” I mean it was such an easy thing to fix, why didn’t we think of fixing it before? I think in medicine we don’t look at the obvious, and Dr. Litvak made us look at the obvious, and it’s much better.
SUSAN DENTZER: Given the results in Boston, and at other hospitals Litvak has advised, his approach is now catching on. The national hospital oversight body, the Joint Commission on Accreditation of Health Care Organizations, now recommends that hospitals use scientific management principles to help address ED overcrowding.
Meanwhile, Litvak and his Boston colleagues now plan to conduct further research. They hope it will show that making hospitals more efficient will produce fewer medical errors and better outcomes for patients.