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Coffee and Colic

2005; Lippincott Williams & Wilkins; Volume: 27; Issue: 10 Linguagem: Inglês

10.1097/00132981-200510000-00030

1552-3624

Shari J. Welch,

Infant Health and Development

Millions of Americans line up each morning to shell out $4 for one of Starbucks' premium beverages. But how long is too long to wait for a vanilla latte? The Seattle-based chain is broadening its menu to include some hot breakfast items but trying desperately not to lose any of its 33 million weekly customers in the process. “This is a game of seconds,” says Silvia Peterson, the director of store operations engineering. Her team of 10 engineers is always looking to shave time off coffee-making operations. (The Wall Street Journal, April 12, 2005.) Does Starbucks have anything to say to the emergency physician?FigureFive years ago it took on average three and a half minutes from the time a customer got in line until his order was delivered. Through quality improvement research focused on operational efficiency, Starbucks shaved 30 seconds off this time, and increased revenues $200,000 per outlet. Engineers discovered, for instance, that a particular volumetric ice scoop helps Starbucks' baristas turn out a frappuccino 14 seconds faster. This is a great parallel for the emergency physician. Who wouldn't love to see a subset of patients with a turnaround time of three hours be moved through 14 minutes faster? Starbucks uses data to guide its operations, and clearly EDs should be doing the same Starbucks knows it takes 20 seconds to deliver a tall black coffee and 90 seconds for a venti double chocolate chip frappuccino blended cream. Does the typical emergency physician or manager know how long it takes to get a chest x-ray in his department? How long does it take to get an analgesic when a patient presents with renal colic? Does he know how many chemistry panels will be drawn on the evening shift, and how long it will take to turn them around? Can you think of any other $4 million business (a rough estimate of emergency physician billings per hospital per year) where this type of data would be unstudied and unknown? Starbucks executives have added a floater to take the customer's order, mark the cup with the drink code and pass the cup to the barista. Previously the barista did the entire process, which often left the customer sitting at the register untended while large orders were being filled. This change in operations shaved 20 seconds off overall time and improved customer satisfaction by starting the drink preparation process sooner. Isn't this the same principle involved in bedside registration and shorter door-to-doc times? Industry Analogies The industry analogies to ED operations are limitless, and when QI principles are applied to efficient service in treating painful conditions, there is an opportunity for important gains in clinical care and patient satisfaction. Pain is one of the major symptoms that cause patients to seek medical care on an emergent basis, and a direct correlation between pain relief and patient satisfaction has been shown. (Acad Emerg Med 1998;5[9]:851.) Pain management in children in the ED correlates highly with patient satisfaction (Acad Emerg Med 2002;9[12]:1379), and timely alleviation of adverse symptoms has been shown to deter patients from leaving before they have been seen by a doctor. (Ann Emerg Med 2003;42:3.) As Starbucks executives discovered and numerous emergency medicine studies have shown, the relationship between wait time and patient satisfaction is irrefutable. (J Emerg Med 2004;26[1]:13.) Increasingly patient care protocols are considered best practice innovations because they accelerate the care of subsets of patients in the emergency department and eliminate unnecessary variation. (MacGrayne J. ED Benchmarks and Best Practices. Presentation at Benchmarks 2005, Orlando, March 2005.) The ability to expeditiously and consistently treat painful conditions in the ED has a positive effect on patient satisfaction. One subset of patients which could be moved through the ED system more quickly and have pain issues addressed very rapidly are patients with flank pain secondary to renal colic. A patient care protocol based on current literature was devised at our institution to facilitate the care of patients with flank pain likely to be secondary to renal colic. (See table 1.) Recommendations were solicited from nephrology groups at our hospital before formulating the protocol. The use of Toradol for renal colic (Am J Emerg Med 1999;17[1]:6) and the use of spiral CT scanning without IV contrast for renal stones (Am J Emerg Med 1999;17[3]:279) are recent innovations noted in the literature, and were incorporated into the protocol. The entire effort was part of a CQI initiative.Table 1: Flank Pain Patient Care ProtocolIt was noted that flank pain was a frequent chief complaint in patients presenting with moderate to severe pain in our department. Our QI data also showed that this group was frequently overrepresented in patients staying more than six hours. While flank pain accounts for less than two percent of our volume, it accounts for eight percent of the moderate to severe pain patients and four percent of patients who stay more than six hours, prompting us to develop a patient care protocol for the timely management of pain and expeditious work-up in these patients. Recent advances in the medical literature were incorporated into this patient care protocol. This is an example of how evidence-based medicine and CQI efforts can come together to suggest innovations in ED operations. Such innovations are beginning to be described in the literature. (Emerg Med J 2004;21[5]:537; Am J Emerg Med 2004;22[6]:460.) Eliminate Variations Patient care protocols are advantageous in myriad ways. They eliminate unnecessary variation in care, which in turn reduces the chance for medical error. They also empower the staff to initiate care within certain guidelines before the physician's direct contact, with very low risk and high benefits. The care is noninvasive and the advantages in timeliness of care are obvious. The flank pain protocol shaved 20 minutes off the turnaround time of flank pain patients in our department by empowering the nurses to immediately begin treatment for pain and nausea and to expedite the work-up. (See table 2.) Since its implementation, there have been no adverse effects. Granted, this is the experience of one department, a QI project, and not a prospective, randomized, controlled study.Table 2: Patient Volume and TAT for Flank PainStill the findings are provocative, and should inspire other emergency physicians to tinker with their operations in the quest for efficiency and improvement. One subset of patients at a time, using data and evidence-based medicine as a guide, emergency physicians can begin to move patients through their departments even more efficiently and safely. Starbucks tries out its innovations and improvements in different markets and outlets. The company uses data to guide its operations. Clearly we should be doing the same.