Have you ever noticed that some things everyone seems to know and believe, end up being false all along?

“If the ED only saw ‘true-emergencies’, ED crowding and costs would improve.”

“Many patients don’t need to be in the ED.  We would save money by sending them somewhere else.”

The dream of High-Acuity, ‘true-emergency’ EDs assumes:

1. It’s possible to educate patients to go elsewhere.

2. Patients have somewhere else to get care.

3. Staff can safely tell who is a ‘true-emergency’ and send all others elsewhere.

4. Low-acuity patients crowd the ED and shouldn’t be there.

5. We can save money by decreasing low acuity ED visits.

This is nonsense.  Here’s why.

1. Patients attend the ED for access, not because they are stupid.  Most patients don’t need education.

2. Patients come to harm if sent elsewhere. (JAMA)

3. Low-acuity patients do NOT crowd the ED.  They cycle through quickly.  Sick, admitted patients crowd the ED.

4. Marginal costs for minor patient complaints are minuscule:  pennies compared to the cost of keeping the ED open.

One more point:

‘True-emergencies’ don’t trickle in one at a time.  ‘True-emergencies’ often present in batches.  In larger EDs, three critically ill patients often present at the same time, and most providers can recall a time when 4 critically ill patients showed up within minutes.  Each critically ill patient requires up to 4 nurses, a physician, a respiratory technician, and more.

Efficiency: What kills it, and what can we do?

Why do governments close low-volume EDs even if they have money to keep them open?

Small EDs often have many hours when they see very few patients.  An acute care resource running at anything less than full capacity wastes money.  Idleness equals waste; it kills efficiency.  

Has anyone solved this in healthcare?

Consider a trauma room:  most hospitals keep one or more operating rooms open (staffed), at great cost, in case trauma or emergency surgeries come in.  Idle trauma rooms cost a ton of money. Hospitals often recover some cost by managing non-emergent cases, especially if the team has already been called in and a suitable admitted patient awaits surgery.

Hospitals eliminate idleness to increase efficiency.  Hospitals recover cost and gain efficiency by using the trauma room for less urgent, non-trauma patients!

Even IF there was a way to figure out which patients were ‘true emergencies’, EDs large enough to manage all the ‘true emergencies’ in a community would stand idle much of the time at HUGE cost.  EDs recover cost and gain efficiency by seeing less-acute patients!

The efficiency found in an ED that never sits idle will always crush a mythical ‘High Acuity’ ED.  

How do you approach efficiency in your ED?  How would you deal with ED idleness if you could identify and safely send away all the non-true-emergencies?

In another post we’ll discuss safe ways to meaningfully reduce demand on EDs.  Please leave a comment by clicking Leave a Reply or # Replies.