Patients are waiting

Editorials / Commentaries

CJEM 2001;3(4):263

See related article: EM Advances

In this issue, Lazarenko and colleagues¹ describe the potential time saving achieved by moving laboratory-based pregnancy tests to the emergency department (ED). One might think: Who cares? Or one might assume, as I did, that all EDs already do pregnancy tests. But when a friend told me that his hospital laboratory also prohibits point-of-care (POC) pregnancy tests, I asked around and learned that many Canadian EDs depend on lab-based testing.

When a patient's treatment or disposition depends on a test result, faster testing facilitates faster treatment and shorter ED length of stay (LOS). For those who don't work in an ED, a few hours of stretcher time seems trivial, but it's not. Efficiency has become critical, and the more patients we can care for in a plummeting number of available stretcher hours, the fewer we will leave untreated in our hallways. Lazarenko and colleagues found that POC pregnancy tests could potentially have freed up 475 hours of ED stretcher time -- enough to treat 194 migraines, 307 myocardial infarctions or 5708 drug-seekers demanding Percocet.

In my ED, all the stretchers are occupied all the time. If you stagger in with a bowel obstruction or pneumonia, you will be triaged to a waiting room or hallway -- the only spaces available. But we are adapting to this. We've learned to palpate abdomens by reclining patients in their chairs and we've instituted physician order entry, which allows us to order tests and x-rays on people who may never get to a stretcher. We don't undress people in the waiting room, of course, and we don't do rectal or pelvic exams. Hallway patients receive poor evaluations and inadequate symptom relief. And they vomit in wastebaskets.

In such a setting, if there is a single patient lying in a stretcher -- just waiting -- it is a misuse of medical resources. Yet many patients do just this. Patients referred in to see specialists all seem to wait from 11 am until 5:30 pm when office hours end. Stable patients lie in stretchers waiting for ultrasounds, CT scans or lab results. Many patients wait 2 hours for a consulting service to respond and 3 more hours for an admission decision. Admitted patients who already have beds upstairs can't go to them because wards won't accept new patients until after shift change. Discharged patients wait in ward beds until 6 pm when a family member can come to drive them home.

Would any sane person design a system like this? No! We need to reconsider our processes, to look at who we put in stretchers, how long we leave them there, and where they wait after assessment. We need to question how much diagnosis and treatment is necessary in the ED. We need to streamline our diagnostic and discharge processes, and educate our consultant colleagues about the value of ED stretcher time. A health economics expert at our hospital recently told me that the average cost of an ED visit is $400 -- about $133 per hour. One could argue (correctly) that EDs have high fixed costs and that this is not the real cost of an ED stretcher, but the numbers should make us think carefully about how we use stretcher time.

Your imaging director may tell you it is cheaper to observe a head injured patient than to do an off-hours CT, but if other patients need the stretcher, she is wrong (the cost of not treating patients is higher). Your lab director may tell you that POC tests are expensive and evil, but in situations where a POC test will reduce LOS and improve another patient's access to care, he is wrong. In today's world, ED stretchers are our most valuable resource, and ED length of stay is the home of cost effectiveness. In today's world, patients should not "wait" in ED stretchers.

Reference

1. Lazarenko GC, Dobson C, Enokson R, Brant R. Accuracy and speed of urine pregnancy tests done in the emergency department: a prospective study. CJEM 2001;3(4):292-5.