In 1999, the Institute of Medicine (IOM) reported hospital errors were responsible for 99,000 deaths/year, making hospitalization the fifth leading cause of death in the United States (US). Today, despite the development of a robust patient safety movement fueled by the IOM report, hospitalization is the third leading cause of death accounting for upwards of 400,000 preventable deaths/year (James, 2013). Consider that it would take two 747 Jumbo Jets crashing every day to approach the number of annual deaths attributed to hospital medical errors. If this happened in the airline industry, no flight attendant, navigator or pilot would fly until the problem was fixed. Yet, healthcare providers work every day in settings prone to causing harm. Why do providers continue to work under these conditions?
The reason is complicated, but a personal experience may shed light on one of the answers. As a case manager in a busy, urban, intensive care unit, barely a day went by during rounds when we did not discuss a patient that, (a) was at risk for…or, (b) was suspected of having…, or (c) had developed…, or, (d) was critically ill fighting off…, or (e) had just died from…a central line infection. We ‘talked’ a lot about central line-associated bloodstream infections (CLABSI), almost as if they were an undesirable, but eventual byproduct of the work we were doing. It was not until Peter Pronovost came along and virtually eliminated CLABSI at Johns Hopkins Medical Center, and then validated his work by eliminating CLABSI throughout the state of Michigan, that we, as an industry, began to see there was another way (Pronovost et al., 2010). Pronovost saved many lives and in doing so bent the culture of healthcare towards understanding that providers already possessed the ability to ‘Get to Zero’… and that all they needed was the willingness to eliminate a pernicious source of harm.
There are many drivers to harm in the healthcare industry. In addition to hospital-acquired infections, risk is created by the increasing complexity of and reliance on technology, the overuse and misuse of medications and other technologies, efforts to cut costs and increase productivity, and the financial incentive in a fee-for-service billing environment to use invasive technology. Nowhere do all these drivers to harm come together in a more visible way than in our nation’s emergency departments.
Emergency department (ED) utilization continues to outpace population growth. Since 1999, visits have risen from 103 million (378 visits/1000 persons) to almost 130 million (428 visits/1000 persons) in 2010 (Centers for Disease Control, 2014). As the Affordable Care Act is implemented and more people obtain insurance coverage, it is likely there will be even higher ED volumes. Emergency department crowding and the resultant long wait times are a predictable and common condition across a wide range of hospital types. The ED waiting room is sometimes referred to in the popular press as ‘the most dangerous place in the hospital’ because some patients suffer harm due to a long ED wait times (Hoffer, 2014).
The primary cause of ED crowding is the practice of holding, or boarding, admitted patients in the ED (IOM, 2007). As these boarded patients consume an increasing share of the ED’s resources, waiting times throughout the ED, and especially in the waiting room, increase to often unsafe levels. Emergency department crowding causes two serious issues that expose patients to the potential for harm. First, when people wait for long periods to be seen, some will give up and leave before being seen (LBBS). This represents a denial of access to care and puts patients at risk for harm. The second effect is that patients boarded in the ED, often for long periods (sometimes measured in days, not hours), may suffer worse outcomes than patients admitted expeditiously. Research has demonstrated that ED crowding causes higher rates of complications and has been implicated as a cause of greater in-hospital mortality (Bernstein, et al., 2009; Chalfin, Trzeciak, Likourezos, Baumann, & Dellinger, 2007). McCusker. Vadeboncoeur, Levesque, Ciampi, and Belzile (2014) reported that once an ED was crowded, a 10% increase in ED occupancy led to a 3% increase in inpatient mortality. To shine a light on these ED processes, the Centers for Medicare and Medicaid Services (CMS) has recently required hospitals to measure and report their LBBS rates and boarding times.
Changes in ED Service Delivery
Over the last 15 years, there has been increasing focus on reducing emergency department ‘access block’ and associated, suboptimal outcomes. Multiple stakeholders have identified ED process improvements with the goal of reducing crowding. Both the American College of Emergency Physicians (2008) and the Emergency Nurses Association (2014) have issued position statements and/or toolkits for reducing crowding. The Institute for Healthcare Improvement (n.d.), the Agency for Healthcare Research and Quality (2011), Urgent Matters (n.d.), and the Robert Wood Johnson Foundation (n.d.) are several of the national organizations that have recommended a ‘bundle’ of strikingly similar solutions for eliminating boarding and improving patient flow. Recognizing that ED crowding is a hospital problem, not an ED problem, The Joint Commission placed its ‘ED patient flow’ standard in the Leadership domain.
I have worked with two hospital ED quality-improvement collaboratives and have facilitated the implementation of strategies that significantly reduced LBBS rates and the amount of boarding time at hospitals with diverse characteristics. While the specific strategies were important, it was crucial that ED leadership and clinicians were willing to reimagine the way in which the ED did business. The traditional model of ED care is linear in nature: arrival > check- in > triage > registration > waiting room > treatment room > physician evaluation > testing > treatment room > disposition. For every task there is a designated location and frequently a delay.
The new paradigm takes advantage of parallel processes. Triage and check-in both occur on arrival. The patient is immediately taken to a treatment area (most ED patients do not need a room or bed -- a strategy called ‘Keep them vertical’). At the same time or very shortly thereafter the physician evaluation occurs and testing is initiated. This ‘strategies bundle’ used to facilitate ‘front end’ flow is generally called the Rapid Intake Strategies bundle. By using these strategies many hospitals have been able to eliminate waiting room delays, dramatically reducing their LBBS rate. One hospital I worked with eliminated the waiting room itself.
Hospitals have also worked on their ‘back end’ strategies to decrease boarding. Again, a paradigm shift was called for. Instead of being a ‘push’ organization, where ED staff struggled to get admitted patients to the nursing units (one hospital reported that on average 13 telephone calls were required to admit a patient), hospitals identified and implemented a vision where the nursing units ‘pulled’ patients out of the ED shortly after the decision to admit was made. To do this, hospitals created ED flow coordinators whose job was to interface with the teams on the nursing units to keep them informed about pending admits. Demand forecasting helped nursing units set staffing levels based on predicted admissions rather than the midnight census. ED teams successfully negotiated, and supervisors enforced absolute time limits for boarding. ‘Holding Orders’ were written by the ED physician when inpatient physicians delayed seeing their patients in the ED. By the end of the collaborative, we saw over twenty-five different strategies used by these motivated hospitals to reduce their LBBS rates and boarding times (McClelland, 2014).
Just as Pronovost demonstrated that Get to Zero was an obtainable goal for CLABSI, these hospitals demonstrated that once the willingness was created, they had the ability to mitigate ED crowding and its potential for harm. Now that we know there is a delivery system that results in the virtual elimination of LBBS and boarding time, are all hospitals ethically bound to implement the best practices tested and shown to mitigate ED crowding?
Ethical Principles Calling for System Change
Beneficence is an obligation to assist others in their pursuit of important and legitimate interests. Beneficence includes the identification and removal of possible harms that may deter these pursuits (Stanford Encyclopedia of Philosophy, 2013). Beneficence is most frequently associated with individual actors, i.e. a nurse acting with beneficence while caring for a patient. However, it applies to groups as well. For example, a state government is acting with beneficence when requiring immunizations to prevent the spread of infectious disease throughout the population. Hospital administrators and ED leaders and providers are not acting with beneficence when they allow excessive waiting times as a predictable occurrence in their EDs. Related to beneficence is the corollary of non-maleficence, which is an obligation not to harm others. The evidence informs us that EDs characterized by long waits and high LBBS rates are contributing to institutional harm.
Respect for a person’s autonomy creates an obligation on the part of healthcare workers to respect decisions made by patients even though they may not agree with them. In the immunization example, the state government demonstrates a respect for autonomy by allowing ‘opt out’ procedures. When a person makes the decision to seek ED care, they are acting to meet an important personal need. ED providers are not practicing respect for the patient’s autonomy when they feel they ‘know better’ than the patient and discount the individual by maintaining barriers, based on a perception that the individual does not really have ‘an emergency.’
Another guiding ethical principle is contractualism. Contractualism has been defined as the existence of an agreement of moral behavior by members of a community (Stanford, 2012). Emergency departments are well established in the US as a source of 24/7 access to healthcare and are required to evaluate all patients, regardless of ability to pay. This stipulation was included in the Hill-Burton law of 1946 that jump-started the hospital industry by paying for new hospital construction; it was codified more clearly in the law called the Emergency Treatment and Active Labor Act (EMTALA) of 1986. Indeed, EDs have been recognized as the safety net for the under-insured and uninsured. In this case, EDs are always open for evaluating health problems, and people are always morally empowered to seek care. When ED providers develop and maintain systems of care that create barriers to access for those with minor or chronic illnesses, they are really saying, "If you don't play by our rules you are not welcome." Emergency departments reaching for the moral high ground say, “If we build it, they will come” and welcome all patients as legitimate.
More than any other setting, the ED mirrors the characteristics of the entire healthcare industry. The ED is simultaneously inpatient and ambulatory in nature, it treats patients across the acuity spectrum, provides medical, surgical, and psychiatric services, requires care coordination to be optimally effective, and employs a wide range of provider types. As such, EDs can serve as laboratories for reform. If we can fix EDs, we can fix all of healthcare. The relatively small numbers of hospitals that have made the culture change to become porous, patient-centered, and efficient have demonstrated to the rest of the industry an ability to implement best – and ethical -- practices. Having identified the ability to Get to Zero on LBBS and boarding time, it is up to the rest of us to develop the willingness.
Mark McClelland DNP, RN, CPHQ