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ED Eliminates Diversion and Shortens Waits, to Boot

2007; Lippincott Williams & Wilkins; Volume: 29; Issue: 11 Linguagem: Inglês

10.1097/01.eem.0000298820.86969.b7

1552-3624

Anne Scheck,

FigureTim Johns, MD, has a one-word description for the common belief that emergency departments lose money. “It's a myth,” he said. He doesn't argue that the misconception is a reality in some places, but certainly not at his hospital, where last year more than 7,000 patients were treated without being able to pay. Were they uninsured? Illegal immigrants? Primary care patients seeking care in the ED? It didn't matter. “We happily and rapidly see all,” said Dr. Johns, a founder and the medical director of Gilbert Hospital in Gilbert, AZ, a suburb of Phoenix. “Our staff does not even know who is insured and who is not.” Gilbert Hospital opened its doors about 18 months ago, and the for-profit acute care general hospital not only is making money, but physicians see patients within about half an hour of check-in. New patients need only give their name and birthdate before treatment starts; registration is done later at the bedside. (A barcode-bearing card, called an SST for “sign-swipe-treat,” is issued at the initial visit and used on subsequent ones.) If patients wait more than half an hour, they are given movie tickets and a personal apology from Dr. Johns. Movie tickets? “It is a thousand little steps,” he said, explaining that state-of-the-art technology — fast computers for speedy registration, point-of-care testing, and new diagnostic imaging — make for quicker assessments. Perhaps most important, though, is that the staff cooperated from the ground up in finding ways to streamline patient flow. “If a patient needs a bed, put him in a bed,” Dr. Johns said, describing the approach. At Gilbert, “it became not so difficult to meet standards that are supposed to be so difficult,” he added. Tight Time Standards There is no guarantee or any attempt to “push patients through the system,” Dr. Johns stressed. “However, we do adhere to very tight time standards on lab and imaging turnaround times, medication times, re-evaluation times,” and other necessary procedures, he said. Why does it work so well? Maybe because this is a hospital that physicians, including Dr. Johns and other emergency physicians, helped build with a group of investors. Initially, the proposal for the hospital was stymied; it became clear that traditional lending agencies were not going to finance a plan to build a hospital with an emphasis on the ED. In fact, Dr. Johns was practically thrown out of nearly two dozen banks, he recalled, where loan officers all used basically the same general admonishment: “Don't you know ERs lose money?”Figure: With a budget of $4.1 million, including personal contributions by the physician founders, the Gilbert Hospital ED, shown here, was built on the premise that emergency departments don't lose money.When a medical equipment leasing company learned of the proposed hospital, however, funding suddenly became a possibility after the new medical center agreed to purchase major medical equipment. Once the investors were willing to personally guarantee a long-term lease, the builder was able to secure financing for the structure. “We basically solved that problem,” Dr. Johns said.Figure: Dr. Tim JohnsThe physician founders, who contributed their own money and entered into equity stakes of the enterprise, had done all they could to attract outside investors, and several community members put up sums solely out of what Dr. Johns calls “being concerned citizens” who wanted the facility for Gilbert. In all, 25 investors put their money and their faith into the concept, for which 42 shares in the yet-to-be-built institution were issued, he noted. With a total tenant improvement budget of $4.1 million, they felt ready to move ahead, but then a shortfall surfaced. Even with all the careful projections, the project was shy about half a million dollars. So the future doctors, staff, and even the CEO of Gilbert Hospital took matters into their own hands, literally. They manually transformed the structural shell, tiling floors and painting walls, into a place ready to house the technology and expertise necessary for urgent patient care. “We even did all the millwork, like custom baseboards and cabinets and all of that,” Dr. Johns explained. No Curtains or Cubicles Since its inauguration, the hospital has processed nearly 70,000 patients in Gilbert, a once-sleepy desert town that is now a bustling suburb of Phoenix. Private rooms await all patients, and each room has seating for two visitors. There are no curtains or cubicles, and no overhead paging is allowed except for codes. Patients don't move; procedure carts do. The patient rooms, equipped with a television set and Internet access, rarely keep a patient for more than an hour, and when waiting times lag, complaints are few. And Dr. Johns, who once dreaded going in to a patient room, likes his profession a lot better now. “When a patient has been waiting for 16 hours, I don't care who you are, you are not going to get a good response,” he said. In contrast, at Gilbert, transfers are undertaken immediately to avoid crowding. “We have become very good at finding the right type of bed with the right type of specialist at the right time,” Dr. Johns said. These transfers are followed up within 12 hours to the receiving hospital to ensure the transfer was appropriate and complete, he added. Already underway is an expansion, which will add 16 beds to the inpatient unit. Another 100-bed expansion is due to break ground early this year. The hospital is proof that solutions can be found, even when none seem to exist. “Everybody has been moaning and groaning that this can't be done. But nobody has been getting it done,” he said. At Gilbert, the founders believe they have found a way to eradicate long waits, boost patient satisfaction, and provide top-notch medical care. Dr. Johns doesn't want this to remain a singular accomplishment, though. He said he would like the hospital to lead the way for others, to be copied and refined at different places in the years ahead. From Crowded ED to No Diversion Gilbert Hospital in suburban Phoenix has 320 employees, 128 physicians, and a statistic no other emergency department in its region can report: no ambulance diversion. How does the ED do it? Tim Johns, MD, its founder and medical director, said they did it by focusing on three problem areas. Nursing shortage: Make the work environment enjoyable by supporting each nurse with a paramedic and an EMT, and staff for the daily highest expected volume instead of averages. Let the nurses set policy, and have administration implement and support that policy, not the other way around, he said. There is no limit on salaries, and the hospital has, said Dr. Johns, the “best 401(k) and tuition reimbursement plan” around. “We have a waiting list for nurses applying,” said Dr. Johns. “We have not used temp agencies for more than a year.” Specialist shortage: “We don't try to be all things to all people so we don't try to have all 43 specialties on staff,” Dr. Johns explained. “We do what the Institute of Medicine suggested in its report last year on emergency medicine: partner with those institutions who have centers of excellence.” Gilbert works with regional call systems. Ambulance diversion: Gilbert Hospital hasn't been on diversion since opening, and it doesn't plan to except when there are mass casualties. “Since we never allow our ED to get backed up with ‘admit holds,’ we never have ambulances waiting,” Dr. Johns said. “If our inpatient unit cannot accept an admission within one hour, we find a hospital that can.” Even in the Phoenix market, which is one of the most severely “underbedded” in the country — the national average is 2.8 beds per 1,000 population, and Phoenix is at 1.8 beds per 1,000 population — “we can always find a bed somewhere,” he stressed. — Anne Scheck Quick Facts: Death Rates from Poisoning in the U.S. Poisoning became the second leading cause of death by injury in the United States in 2004, following motor-vehicle traffic deaths. The state age-adjusted poisoning death rate ranged from 4.6 to 19.4 per 100,000 population. States with the highest rates included West Virginia (19.4), New Mexico (18.4), Utah (17.7), and Nevada (17.3). Nine of ten poisoning deaths were caused by drugs, seven percent by inhalation of gases and vapors, one percent by alcohol, and one percent by other substances. Poisoning deaths included deaths classified as unintentional (69%), suicides (19%), deaths of undetermined intent (11%), and homicides (0.3%).FigureSource: MMWR 2007;56(36):938.