ACEP News “30 minute rule” rant

There’s an excellent rant in this Month’s ACEP News (members only section, unfortunately). I’m going to edit it a bit, and I hope you enjoy it as much as I did.

ACEP News
March 2006 By David f. Baehren, MD

….. Whoever thought up the "30-minute guarantee" unknowingly sent what little joy there was in triage to the same black hole that consumes manners, common sense, and lost socks.

Now every nurse manager in the universe is under the gun from the CEO to "do something about waiting times–or else." The "or else" implies either unemployment or the institution of their local version of the 30-minute guarantee.  Patients could be guaranteed free movie tickets, free gasoline, or 10% off a colonoscopy if the doctor fails to meet the 30-minute goal

Of course, everyone knows that patients wait because the doctor is not working fast enough. The solution is to give the doctor more patients to see simultaneously. ….

For a thousand years, I will maintain that patients are relatively happy in their blissful ignorance in the lobby. Move them back to the patient care area where they can be ignored in person, and they really start to get annoyed.

Their ringside seat also makes them instant experts on what the nurses and doctors should be doing with their time. Apparently, talking to consultants on the telephone and reviewing a chart while seated are not acceptable activities. God help you if you eat a handful of nuts to prevent starvation while your lunch from 2 days before grows mold in the refrigerator in the break room.

…Any circus juggler will tell you that there are a finite number of balls that can be put in the air simultaneously. Three are easy; things get hairy with more than 10. Problems and mistakes happen when someone tosses in an anvil (patient with acute coronary syndrome and ventricular arrhythmias), and all the other balls drop to the ground. A few roll under the Pyxis.

Everyone has a threshold where productivity falls as the number of active patients goes up. I think mine is 8.6, give or take a tenth. I could make you a graph, but that kind of thing makes my brain hurt (as my third grader likes to say).  I’ve tried to communicate this thought. Possibly you could do better.

What sense does it make to pile more nonacute patients into the treatment area when the physician says (in a pleasant and reasoned manner) that it will slow him or her down? Putting these patients there may make the triage nurse feel better, improve the "door-to-doctor" time, and keep the CEO off the nurse manager’s back, but it doesn’t help the patient.

And it doesn’t help the doctor. But this antiquated idea is not often spoken of these days. Emergency patient flow is complicated. Few understand it, and those who don’t will continue to try to "improve" it by driving you to distraction unless there is reasoned discussion with someone who makes a lot more money than the poor triage nurse.

They had a discussion like this about bloodletting once.

Dr. Baehren is the author of "Roads to Hilton Head Island" and practices emergency medicine in Toledo, Ohio.

Well said!


Comments

  1. I don’t know how you guys do it.
    I volunteer in an ED where stable patients are usually there for three and a half to four hours. This is from walking in and saying “My finger hurts” to being released.
    One night wasn’t so great. They had a 12 yr old male having some bad heart problems (they were busy which meant I was busy and I never did get to ask what exactly was wrong). Rightfully so, they were working hard on him. Mom was off to the side crying her eyes out.
    A jackass comes out of his room whining about his hurt wrist. “When am I gonna see a doctor? I’ve been here for two and half hours!”
    A nurse passing by stopped and herded him back towards the room saying, “They’ve got a critical patient right now they’re working on. You will be seen as soon as possible.”
    He actually said, “Well, that’s not *my* problem, now is it?”

    I hope they gave him a big IV.

    Wait times will happen. People complain about how expensive medical care is, but want quick service. I’m sorry, but something’s got to give. The extra staff is expensive.
    In an ED nothing is predictable (I know I’m preaching to the choir). If three ambulances show up because Billy nearly lopped his leg off, Suzy is cyanotic, and little Jimmy can’t feel his legs after a bike accident, well your runny nose is just going to have to wait.
    Those CEO’s need to wake up and realize it’s not a coffee shop.

  2. Anonymous says:

    Gruntdoc, the ER is at the front line of the health care crisis and KUDOS to all the ER docs who maintain. The problem is multi-faceted – uninsured using the ED as their sole medical care and also those that refuse to wait for an appointment from their family physicians and the shortage of family physicians/primary care docs, etc. Thirty years ago, no average citizen would have sought medical care in the ER unless it was TRULY an EMERGENCY. Now, we live in an INSTANT GRATIFICATION society that seems intolerant and impatient of anything but some selfish desire. Yes, of course one should wait if one only has a sprained ankle and the ER docs and nurses are tied up taking care of a patient with an acute MI. But the average person won’t accept that anymore and can’t understand why there aren’t more docs and nurses available to take care of his/her medical problem. Many ER post waiting time signs in their lobby and have ancillary personnel try to explain to those waiting for what reason they are being delayed in treatment, but that still isn’t enough. And many hospitals are closing down their ERs because it is a money-losing deal. Yes, the ER is at the front line for the present health care crisis and the war has just begun…

  3. TheNewGuy says:

    I look them straight in the eye, and simply ask the complainers if they’d like to explain their concerns to the mother of the 5yo girl who just died after being run over by the school bus, or to the family of the man who just died of cancer, or to the group of bikers who are waiting to hear if their “brother” is going to be OK after laying down his Harley.

    I’ve yet to encounter an individual who was willing to take me up on that invitation.

    It’s all about perspective… sometimes providing some is all you need to do.

  4. What will happen is a doc will poke his head in the door before 30 minutes and the patient will not get the prize.

    I need to correct a few misconceptions from anon 0637:

    It isn’t only uninsured clogging up ED waiting rooms, it’s insured as well.

    The “societal” change that gave rise to this need for instant gratification was not a societal change at all. It was universal adoption of the “reasonable layperson standard”.

    Simply put, if you believe you (or your child) is sick enough for the E.D., you are presumed to be correct. This means an insurance company cannot deny the claim on grounds the visit was unneccessary.

    It sounded like a great idea at the time, but the result was EDs packed to the rafters with folks who don’t need to be there.

    The ED docs I speak to daily claim that they (the docs) do not care that they are seeing non-emergently ill people.

    So you have patients with no disincentive against going to the ED, docs willing to see them, payors willing to pay, and hospital administrators thrilled at the income.

    Sounds like a win-win-win-win, doesn’t it?

    Flea

  5. ER’s have to take ambulances and careflights first. If you have a big hospital there could be as many as 7 ambulances coming into the bay. If more people understood this then I think there would not be such a commotion. If you have a sore throat or an ankle that you can walk on but is swollen, this is what they have the Non Urgent care centers for. They are everywhere and if people would use these it would free up the ER for Trauma and Critical Care.

  6. I’ve been there on both sides of the aisle as a nurse and a nurse practitioner. Many times I have gotten into arguments with nurses and physicians while I was in charge. If the nurses are too busy to take care of another patient there is no reason to retrieve one from the lobby and add another voice of dissent to the already tense situation.

    One doc I worked with was adamant that I overload my nurses with more patients than they could safely care for. I told this doc repeatedly that if she was willing to do her own VS, bedpans, IV’s, and the other unnecessary tests she always ordered I would be happy to bring more patients back. Strangely she never took me up on this generous offer.

  7. doctordel says:

    I suppose “unnecessary” is relative to the orderer and the order recepient. Your physician may actually have good reasons for the “unnecessary” tests she orders, azygous. Just a thought…

    We have all seen how inefficiently an ED can run. As I speak I have 5 open beds in my 13 bed community ED right now, with 11 patients in the waiting room. The explanation being that the triage nurse does not want to overload the three main ED nurses with patients and is slowly bringing them back to avoid the bolus effect…except this has been the situation all morning and afternoon. If it ever came up why we had furious patients waiting 2-3 hours in the WR before being seen, does anyone think that hospital administration would look anywhere BUT the EPs to explain this delay? Now, I truly appreciate the consideration on the part of the nurses when it comes to ED flow but this is just one of myriad examples of how we can make our work environments more effecient and more pleasant if we actually tried to balance the needs of the system and its cogs (US)with the wants of our consumers. Patients expect the “Google doc” experience-immediate results that must be unfailingly accurate and complete and require next to no effort on the part of the consumer. Google doc is not a realistic expectation in today’s medicolegal climate but it seems even our hospital administrations think that they can have the cake and devour it, too. It does not make much sense…

    Honestly, I really do feel that most patients who seem to be abusing our system are just frustrated at the inefficiencies our healthcare system has generated and perpetuates and are, therefore, to be handled with empathy and respect. But sometimes you cannot help getting irritated at these inefficiencies, be they under institutional control or more widespread in nature. And, of course, we feel like we are caught in the middle of it all because we are ultimately responsible for our patients but have little control over the great majority of the patient encounter as we work in a hospital with employees that are not affiliated with us except in location only. The hospital and its employees mandate the rules and system under which we work and provide care. They have their interests and we have ours. Are they the same?

  8. doctordel says:

    BTW, please ignore the typos in preevius post; brane-fry.

  9. This makes me love my job even more:

    If a bed is empty, a patient is in it, period.

    They would rather wait in a room, with a nurse to start their IV, get their blood work going, hang a fluid bolus, give them Tylenol, give them Toradol if they appear to have renal colic (and no contraindicatons), get them under a warm blanket and and order an xray if required. They would rather have a nurse taking care of them than than sit in a waiting room with coughing, vomiting people.

    Now, the best part of my job is that we have THE shortest wait time of any ER in the area.

    The doctors don’t WANT the patients in the waiting room. I can do all of the above prior to the patient seeing the doctor but quite often the doctor is right behind me. One meets all paramedics at the bedside and gets report with the nurse.

    And we are busy – for our rather small (comparatively) 11-13 bed ER community hosptial (known for its cardiac care). A doctor can see 50 people a shift (for us that is a lot).

    But I can top the 30 minute rule. A local hospital had an ad campaign that said “It will take you more time to read this ad than to be seen in our ER”. Now that’s taking it a bit to the extreme…..then again, perhaps you’ll be “seen” but that’s about it…LOL!

  10. quartered says:

    50 in 12 hours is impressive, especially if there is no mid-level assistance. I work in three EDs, two of which are small, 13 bed community types where we are single coverage for the whole day with mid-levels during 10-12 hours as well. I hear stories of 4.0, 4.5, 5.2 pts/hour and have to just shake my head in amazement. The proximity to several nursing homes around Houston, combined with the seemingly-ubiquitous 4 month old with fever and an unconvincing upper respiratory source all seem to keep me in the 2.0-3.0 range. I can only hope it gets smoother as times goes on (I finished residency last June.)

    Vis-a-vis your ED’s wait policy, I am a huge fan. If there’s an open room, fill it up, I say. I have never found that patients are happier in the waiting room, as I recently read, than they are once they have reached “Their Room.” The WR can be decidedly unpleasant to the eyes, ears, and nose-we all spend as little time out there as we can, after all. When a patient is expeditiously moved into a room from triage they are immediately (and perhaps unconciously) elevated into a more agreeable, more communicative, more collaborative sate of mind. Percolating in the WR justs seems to irritate people, so that by the time you see them they are already itemizing the myriad ways the ER and it’s staff are completely incompetent. It doesn’t take (enter cliched metaphor indicating superior intellectual capacity here) to realize that, over time, the longer you keep people in the WR, insured patients will just go elsewhere (if they have a choice, as they do in this VAST metro Texas Medical Center) and the self-pays will get ticked off, maybe enough to not pay their bills, seeing as how we disrespected their time and all.

    One of my hospitals has come up with a great plan to have the EP medically screen each and every triaged patient immediately after triage in a sort of mini-holding room adjacent to the WR. The idea is to funnel every patient through this room where I will then screen them, determine if they have a medical emergency or not, then tell them that they are to provide insurance information or a co-pay if they do not have a medical emergency and they still wish to be treated in the ED. This process was mandated to our group by the hospital in an effort to discourage self-pay admissions through discouraging self-pay use of our ED in general. So, we always seem to have at least a few open beds in between quick in-and-outs while the EPs are shuttling back and forth between caring for the sicker patients in the back and screening the freshly-triaged patients in the front. As you can imagine, our waiting times have significantly increased but this maybe the desired effect anyway, since even self-pay patients will only wait so long…

  11. It may be slightly cynical, but a longer wait time (after being competently triaged) usually amounts to a self-triaging system for the toothaches and baby’s-daddy-wants-a-pregnancy-test non urgents. I like to call it disposition by attrition.

  12. If a patient is really sick, we will usually find a way to see them as soon as necessary. If a patient is sort of sick, they will wait and won’t complain much. If they aren’t really that sick, they will complain and/or leave.

    I’m an ER doc in the Texas Medical Center too, and most of the patients I see won’t go to other ERs because they like their own specialist or primary doc to admit them, and our hospital is usually so full they won’t take transfers from other facilities (thus the wait in the ER – we’re often full of patients waiting on hospital beds). And besides, they won’t get seen any faster at another facility anyway. We’re all busy most of the time.

    It’s still fun. :)

  13. I suppose “unnecessary” is relative to the orderer and the order recepient. Your physician may actually have good reasons for the “unnecessary” tests she orders, azygous. Just a thought…

    Smacks forehead with hand. After treating over 100,000 patients I might have an idea what is necessary and unnecessary. And the term “Your doctor” I find particularly obnoxious condescending and rude doctordel. And no this physician does not have a good reason for ordering unnecessary tests. She is an arrogant rude condescending bitch who would do the opposite of what was requested by the nurses to the detriment of the patient, just because she could.

    Glad I don’t have to work with pricks like you anymore…

  14. doctordel says:

    Wow, azygous. Certainly not the reaction I was trying to elicit. Obviously your interpretation of my comments was vaaaaaaaaastly different from the thoughts behind them. Incidently, I said “your doctor” as a posessive term as this physician is only in this discussion because you brought her up, not to imply your subordination, if that is what you are suggesting I did. “Unnecessary” to you may have also been “unnecessary” to her once upon a time…until the lack of that “unnecessary” test was brought up by a plaintiff’s attorney and suddenly became very “necessary” although it seemed “unnecessary” at the time of the patient encounter. All I am saying is that we probably never fully understand people’s motivations for what they do; 100,000 plus patients treated undoubtedly has taught you that. But I will not pretend to know your motivations or rationale; I am not questioning your judgement or your compassion…By the way, am I still a prick if I am a woman? You don’t have to answer. Best wishes, azygous.

    Our hopital will be implementing a medical screen procedure that sounds similar to that described by quartered and our group is trying to hammer out the logistics of efficieently running it. Does anyone else have something similar in place and, if so, do you have any friendly suggestions for how to get it to run smoothly (i.e. added personnel, such as techs, nurses or mid-level coverage, or physical changes to your department, etc.)?