An account of how a large Catholic medical center has lost its way. Go to pmmdaily.blogspot.com to see recent updates.

Tuesday, March 14, 2006

Emergency Room Overcrowding

Emergency Room Overcrowding

The letter I wrote to Keith Steffen, adminstrator at OSF-SFMC, dated September 27, ‘01, described my thoughts and concerns about the OSF- ER after working an afternoon shift the day before. Elderly patientes signed out and went home because they just didn’t want to wait for a bed in the hospital to open up so they could be admitted. I felt very uneasy signing these sick people out of the ER to go home.

The Annals of Emergency Medicine headline an article in the January, 2000 issue “Overcrowding in the Nation’s Emergency Departments: Complex Causes and Disturbing Effects”. During the 90’s, overcrowding in emergency departments became a national issue. It didn’t just involve OSF in Peoria. The article stated, “ED overcrowding has multiple effects, including placing the patient at risk for poor outcome, prolonged pain and suffering of some patients, long patient waits, patient dissatsifaction, ambulance diversions in some cities, decreased physician productivity, increased frustration among medical staff, and violence….Unless the problem is solved in the near future, the general public may no longer be able to rely on ED’s for quality and timely emergency care, placing the people of this country at risk.”

In my opinion, this described OSF-ER almost perfectly. Thus, when I wrote Steffen my concerns and then met with him for the first time in early October, I had no idea that he would metaphorically refer to me in the meeting as a “cancer in the ER that needs to be cut out before it metastasizes” as well as a “hemorrhage that needs to be stopped before the bleeding gets out of control”. How his medical descriptions of me as a cancer and a hemorrhage related to bed capacity and overcrowding at OSF, remained a mystery to me. He didn’t seem to be focused on the important issues for OSF. He seemed to be focused on the concept of fear amongst employees and finding out from me which nurse started a petition in support of me and the problems I had addressed. And the ER director, George Hevesy, put me on probation for 6 months from working the ER the day after I sent this letter.

Almost a year after Steffen fired me from OSF, an article appeared in the journal “Academic Emergency Medicine”–The Elusive Nature of Quality. It discussed that systems need to change before emergency rooms can change for the better:

“Front line care providers (doctors working in the ER) are the frequent targets of criticism regarding the quality of care, and are often the recipients of the metrics we use to measure quality. These dedicated, skilled, and talented clinicians are often powerless when systems changes are needed, but they are held accountable for their actions within a SYSTEM THAT CANNOT ALLOW SUCCESS.

“The true route to achieving quality begins with an enduring commitment from the highest leaders of the organization, willing to exercise their authority for productive benefit. If the board of trustees and the CEO do not actively support excellence in the ED, enduring improvements are unlikely.

“If the messasge is not loud and clear that the patients in the ED must be served optimally by every service with impact, then mediocrity will be the norm. Responsibility must be properly allocated, which is a task of the leaders. No system is successfull without effective leadership.

“If we accept that the formula for quality begins with leadershhip, then the top of the hospital administration must set the expectations for all critical congributors to the ED.

“The essential element of leadership is strong principle.”

These paragraphs define the situation perfectly, in my opinion. However, Steffen and Hevesy must not believe in their validity based on their punitive actions against someone who pointed out to them the problem that needed their attention. And both Steffen and Hevesy told me that there were serious problems with leadership in the
OSF-ER.

On June 3, ‘05, a tiny article appeared in the Journal Star: “Peoria Hospital Opens New Emergency Unit”:

“OSF-SFMC opened its new $2.4 million Emergency Care Unit on Thursday. The 13-bed facility…will serve as an observation area for patients with chest pain, heart failure and asthma.

Mike Cruz, the assistant director of the OSF-ED stated, “It should help significantly…because of the operational components. This will increase total capacity (for emergencies) by about 30 percent. Given that we haven’t had a new facility recently and there has been a volume increase…it will help”.

Notice that it wasn’t Hevesy or Steffen that made this announcement to the public. This needed to happen years before and “the main campus (downtown OSF) had been ignored” according to Dr. Tim Miller in OSF administration when I met with him in September, 2001, after I had written my letter to Steffen.

In April, 2006 when OSF announced its new 234 million dollar campus renovation, Keith Steffen stated that this would include a "much needed" improvement in the Emergency Room which was built for 32,000 patients but is currently expected to have 62,000 visits in 2006.

Why did Mr. Steffen refer to me as a "cancer in the Emergency Department" when I brought the OSF bed capacity problem to his attention in 2001?

OSF’s leadership definitely is lacking, not based on strong principle, and needs a change.

------

Hi Everyone,

It is October 17, 2011.

I posted this today.

Hope you are well.

John

-----------

Dear Everyone,

Today is December 6, 2012.

Hope you are all ok.

This article is from Annals of Emergency Medicine 2012 and regards how ED overcrowding contributes to patient mortality.

I hope you have a good Christmas and healthy New Year.

John
--------

Hi Everyone,

Today s September 4, 2016.

This article is good---

Emergency Medicine News:
doi: 10.1097/01.EEM.0000499520.43380.d1
Special Report
Special Report: Meet the Man Who Solved the Hospital Overcrowding Problem
Shaw, Gina



If you're tired of news coverage about crowded emergency departments and long wait times that focus on the ED as the source of the problem, then Ukrainian-born mathematician and systems engineer Eugene Litvak, PhD, is your new best friend. He has been applying his prodigious intellect to optimizing patient flow and staff coverage in U.S. hospitals for more than two decades.

Figure. Dr. Litvak r...

Virtually every emergency department has things that can be improved, but Dr. Litvak said the ball of hospital overcrowding does not lie in the ED's court. “One of my favorite jokes is about the drunk man walking around under a street lamp at midnight. A police officer asks him what he's doing, and he says that he's lost his wallet. The police officer asks where he lost it, and the man points over to a darkened parking lot. ‘So why are you looking here?’ asks the police officer. ‘Because there's more light,’ the man says.”
The story of how Dr. Litvak figured out where we should be looking for the cause of hospital overcrowding and inefficiency starts with his arrival in the United States in 1988, virtually destitute. Applying for an exit visa to immigrate to the United States from the former Soviet Union tanked his glittering research career in computer systems reliability and telecommunications: He was fired from his academic position the day after he applied, and he spent the next couple of years doing menial jobs like delivering telegrams. His wife, Ella, washed floors. Over the next eight years, he organized and led a new team solving optimization problems for road construction.
But he had been able to keep in touch with his U.S. colleagues, who advised him where to apply his considerable intellect once he finally made it to this country. “They said, you can go to airlines, you can go to any transportation, you can go to banks. But never, never go to health care,” he recalled. “They said, ‘Those people don't care about efficiency. They have plenty of funding, and they are not trying to streamline their operations.’”
To Dr. Litvak, that declaration was “like a red flag to a bull.” He couldn't understand why the most costly industry in the world had no interest in improving its efficiency. Surely, he thought, CEOs of American hospitals would be savvy enough to recognize the benefits of streamlining their operations. So he began sending letters to those CEOs, offering his services.
“Very quickly I learned that my colleagues were right,” he said. “Nobody was interested whatsoever. In fact, most of them did not respond at all. The best I received was a polite ‘Thank you very much for your interest.’”
Despite his dismal initial reception, the tenacious Dr. Litvak — who worked as a night hotel clerk to pay the bills during his first lean year in the United States — wasn't about to give up on health care. He began studying the industry in more depth, and finally was offered a research position at Harvard and then faculty positions, first at Boston University and then at Harvard. He met Michael Long, MD, then a leading anesthesiologist and the deputy director of Massachusetts General Hospital's operating room, in 1996, and formed what would become an industry-changing partnership.

Back to Top | Article Outline
ED Not to Blame
The two men began studying the two main portals to every hospital: the emergency department, which accounts for between 50 and 60 percent of admissions (depending on the location) and scheduled elective admissions, which usually represent an average of about 30 percent of admissions. They found that hospital occupancy was highly variable, with peaks and valleys that frequently differed by as much as 25 percent. That number was closer to 80 percent in unlucky or poorly managed hospitals.
Despite the fact that they account for half or more of all hospital admissions, they found that ED admissions weren't responsible for all the bottlenecks. “If you ask the average person on the street which type of admission is responsible for this variability, they would naturally assume that it's the emergency department. After all, you can't predict when someone is going to break his leg,” Dr. Litvak said. “It's common sense: Emergency care is unpredictable by its nature. But as we learned, common sense and health care delivery are not compatible. Quite the contrary, scheduled elective admissions determine the variability in bed occupancy.”
Dr. Litvak and Dr. Long discovered something that emergency physicians probably could have told them: “If you talk to your ED registrar and ask how many patients you'll admit to your hospital on a particular Tuesday four weeks from now, short of the God-forbid bus crash or epidemic, they can tell you pretty accurately what the number will be,” he said. “But try going to the OR and asking how many surgeries they're going to perform on that Tuesday. You'll never get a reliable answer.”
That is due in part to the block time scheduling that surgeons have. “They have particular hours and days when the OR ‘belongs to them,’” Dr. Litvak said. “They can use it, or if they have a conference or something else, they might not but not reveal that until it's too late for someone else to utilize it. Or suppose you have two high-volume surgeons who both operate on the same day, say, on a Tuesday. What happens there? You know all your beds are going to be taken that day, and you'll have no room for ED patients, but practically, even with that information, what can you do? Tell people not to break their leg that day?”
And the economic incentive is clear: Margins for most elective procedural cases are higher on average than most cases coming through the ED. “Hospitals face financial pressure not to say no to any case that proceduralists want to add on,” said Brent Asplin, MD, the former chair of emergency medicine at the Mayo Clinic, who most recently served as the chief clinical officer for Cincinnati-based Mercy Health. Another factor related to the elective surgical schedule: Most hospitals are still really not seven-day-a-week operations. The intensity of complex cases is typically front-loaded at the beginning of the week, rather than being spread out over the week, and too few patients are discharged on weekends.
In that environment, Dr. Litvak said, hospitals are fluctuating between stress and waste on a daily basis. “There is no reason to staff beds that are never occupied, but when we are staffed below occupancy, multiple studies tell us that we have inflated mortality, hospital-related infections, and readmissions, to say nothing of overcrowding.”
When the peaks and valleys aren't smoothed out, the result can be much worse than just an overcrowded emergency department, Dr. Litvak said. One of the most heartbreaking examples is the case of a 15-year-old named Lewis Blackman. After a successful thoracic surgery on a Thursday in 2000 at the Medical University of South Carolina, the teenager was given the painkiller Toradol, which has the known side effects of perforated ulcers and internal bleeding. Because there was no room in the surgery ward, he was placed in the children's cancer ward to recover. Over the following weekend, Lewis slowly bled to death internally, with his parents' concerns and his increasing pain and other troubling symptoms largely ignored or mismanaged by the on-duty clinical team of residents and nurses.
“This is the result of overcrowding,” said Dr. Litvak. Beds aren't available, so patients are placed in suboptimal beds in different units and nursing resources are stretched thin. Hospitals become really full on Wednesdays and Thursdays [the day Lewis had his surgery], and then there were no surgeons or other experienced physicians around over the weekend to identify what was happening.” This problem and Lewis Blackman's story prompted him to submit an op-ed, “Don't Get Your Operation on a Thursday,” to The Wall Street Journal, which was published in December 2013. (http://on.wsj.com/14RE1BW.)

Back to Top | Article Outline
Rescheduling Surgeries
Dr. Litvak first tested this theory at Boston Medical Center in 2004. The hospital “smoothed out” scheduling of elective vascular surgeries, so that patients coming out of surgery weren't all packing the stepdown unit on Wednesdays and Thursdays. They also designated a specific operating room for emergencies. Next, they took a similar approach with the cardiac surgery schedule, which also hit a peak during the middle of the week. One cardiac clinic day was moved to Wednesday so that some elective surgeries could be performed on Fridays. The result? Stepdown unit variability was reduced by 55 percent, and nursing costs dropped by about $130,000 annually.
“That was the breakthrough,” he said. “People started listening.”
Dr. Litvak was presenting at a meeting in 2003 when a surgeon and vice president from Cincinnati Children's Hospital and Medical Center approached him for help with their patient flow problem. He agreed to take on the project. Dr. Litvak and his team learned at the start that the medical center had budgeted for an additional hospital tower that would have cost $100 million. After implementing Dr. Litvak's flow management system, they didn't have to build a single new bed. “That's $100 million in avoided capital costs, plus improved quality of care, patient throughput, and staff satisfaction,” he said.
Awareness of Dr. Litvak's findings has been steadily growing. He served as the editor of the Joint Commission's 2009 report, Managing Patient Flow in Hospitals: Strategies and Solutions, Second Edition. (http://bit.ly/14vgOWu.) During that same year, he founded the Institute for Healthcare Optimization (IHO; www.ihoptimize.org/), a nonprofit research, education, and service organization focused on bringing the science and practice of operations management to health care delivery.
There's plenty of evidence that Dr. Litvak's ideas work, including a 2012 study that found that nationwide application of the methodology could reduce overall U.S. health care spending by four to five percent (JAMA 2012;308[14]:1439), which is more than $120 billion annually.
But while some hospitals have put in place the IHO methodology in certain departments — Beth Israel Medical Center in Newark, NJ, for example, is saving $10 million a year employing IHO practices in its telemetry department — only Cincinnati Children's has taken a system-wide approach. “Nobody is arguing with us. Nobody's saying we're wrong,” said Dr. Litvak. “It is like cutting through sour cream. There's no resistance, but there's no slice either.”
“Most systems that I am aware of have not yet fully embraced doing something about this,” Dr. Asplin agreed. “One trend, though, that I think could accelerate adoption of the implementation side of this is the competition for capital. There's going to be more and more pressure as payment for health care switches from volume to value-based purchasing. That will mean pressure on capital. You're not going to be able to keep adding expensive ORs which really wouldn't be necessary if you took full advantage of the time available and smoothed out the scheduling.”
Dr. Litvak also urged emergency physicians to raise awareness of his findings within their institutions and in the community. “I don't think emergency physicians should be on the defensive. If I tell you to stop the war in Syria, and you're constantly explaining to me why you didn't stop it, you always lose,” he said. “You need to say, ‘That's the wrong question. We're the wrong ones to be asked this question.’ You can publicize the cause of the problem. Overcrowding is a man-made danger, and emergency physicians cannot overcome it alone, no matter how good they are.”

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

-------------

December 5, 2016

Dear Everyone,

I found this article in Emergency Medicine News today. The article is about hospital overcrowding.

The last sentence in the article is: "Overcrowding (in the hospital) is a man-made danger, and emergency physicians cannot overcome it alone, no matter how good they are."

The article emphasizes the economic incentive for the hospital--

Skip Navigation LinksHome > September 2016 - Volume 38 - Issue 9 > Special Report: Meet the Man Who Solved the Hospital Overcro...
Emergency Medicine News:
doi: 10.1097/01.EEM.0000499520.43380.d1
Special Report

Special Report: Meet the Man Who Solved the Hospital Overcrowding Problem

Shaw, Gina

If you're tired of news coverage about crowded emergency departments and long wait times that focus on the ED as the source of the problem, then Ukrainian-born mathematician and systems engineer Eugene Litvak, PhD, is your new best friend. He has been applying his prodigious intellect to optimizing patient flow and staff coverage in U.S. hospitals for more than two decades.
Figure. Dr. Litvak r...
Figure. Dr. Litvak r...
Image Tools
Virtually every emergency department has things that can be improved, but Dr. Litvak said the ball of hospital overcrowding does not lie in the ED's court. “One of my favorite jokes is about the drunk man walking around under a street lamp at midnight. A police officer asks him what he's doing, and he says that he's lost his wallet. The police officer asks where he lost it, and the man points over to a darkened parking lot. ‘So why are you looking here?’ asks the police officer. ‘Because there's more light,’ the man says.”
The story of how Dr. Litvak figured out where we should be looking for the cause of hospital overcrowding and inefficiency starts with his arrival in the United States in 1988, virtually destitute. Applying for an exit visa to immigrate to the United States from the former Soviet Union tanked his glittering research career in computer systems reliability and telecommunications: He was fired from his academic position the day after he applied, and he spent the next couple of years doing menial jobs like delivering telegrams. His wife, Ella, washed floors. Over the next eight years, he organized and led a new team solving optimization problems for road construction.
But he had been able to keep in touch with his U.S. colleagues, who advised him where to apply his considerable intellect once he finally made it to this country. “They said, you can go to airlines, you can go to any transportation, you can go to banks. But never, never go to health care,” he recalled. “They said, ‘Those people don't care about efficiency. They have plenty of funding, and they are not trying to streamline their operations.’”
To Dr. Litvak, that declaration was “like a red flag to a bull.” He couldn't understand why the most costly industry in the world had no interest in improving its efficiency. Surely, he thought, CEOs of American hospitals would be savvy enough to recognize the benefits of streamlining their operations. So he began sending letters to those CEOs, offering his services.
“Very quickly I learned that my colleagues were right,” he said. “Nobody was interested whatsoever. In fact, most of them did not respond at all. The best I received was a polite ‘Thank you very much for your interest.’”
Despite his dismal initial reception, the tenacious Dr. Litvak — who worked as a night hotel clerk to pay the bills during his first lean year in the United States — wasn't about to give up on health care. He began studying the industry in more depth, and finally was offered a research position at Harvard and then faculty positions, first at Boston University and then at Harvard. He met Michael Long, MD, then a leading anesthesiologist and the deputy director of Massachusetts General Hospital's operating room, in 1996, and formed what would become an industry-changing partnership.
Back to Top | Article Outline

ED Not to Blame

The two men began studying the two main portals to every hospital: the emergency department, which accounts for between 50 and 60 percent of admissions (depending on the location) and scheduled elective admissions, which usually represent an average of about 30 percent of admissions. They found that hospital occupancy was highly variable, with peaks and valleys that frequently differed by as much as 25 percent. That number was closer to 80 percent in unlucky or poorly managed hospitals.
Despite the fact that they account for half or more of all hospital admissions, they found that ED admissions weren't responsible for all the bottlenecks. “If you ask the average person on the street which type of admission is responsible for this variability, they would naturally assume that it's the emergency department. After all, you can't predict when someone is going to break his leg,” Dr. Litvak said. “It's common sense: Emergency care is unpredictable by its nature. But as we learned, common sense and health care delivery are not compatible. Quite the contrary, scheduled elective admissions determine the variability in bed occupancy.”
Dr. Litvak and Dr. Long discovered something that emergency physicians probably could have told them: “If you talk to your ED registrar and ask how many patients you'll admit to your hospital on a particular Tuesday four weeks from now, short of the God-forbid bus crash or epidemic, they can tell you pretty accurately what the number will be,” he said. “But try going to the OR and asking how many surgeries they're going to perform on that Tuesday. You'll never get a reliable answer.”
That is due in part to the block time scheduling that surgeons have. “They have particular hours and days when the OR ‘belongs to them,’” Dr. Litvak said. “They can use it, or if they have a conference or something else, they might not but not reveal that until it's too late for someone else to utilize it. Or suppose you have two high-volume surgeons who both operate on the same day, say, on a Tuesday. What happens there? You know all your beds are going to be taken that day, and you'll have no room for ED patients, but practically, even with that information, what can you do? Tell people not to break their leg that day?”
"And the economic incentive is clear: Margins for most elective procedural cases are higher on average than most cases coming through the ED. “Hospitals face financial pressure not to say no to any case that proceduralists want to add on,” said Brent Asplin, MD, the former chair of emergency medicine at the Mayo Clinic, who most recently served as the chief clinical officer for Cincinnati-based Mercy Health. Another factor related to the elective surgical schedule: Most hospitals are still really not seven-day-a-week operations. The intensity of complex cases is typically front-loaded at the beginning of the week, rather than being spread out over the week, and too few patients are discharged on weekends.
In that environment, Dr. Litvak said, hospitals are fluctuating between stress and waste on a daily basis. “There is no reason to staff beds that are never occupied, but when we are staffed below occupancy, multiple studies tell us that we have inflated mortality, hospital-related infections, and readmissions, to say nothing of overcrowding.”
When the peaks and valleys aren't smoothed out, the result can be much worse than just an overcrowded emergency department, Dr. Litvak said. One of the most heartbreaking examples is the case of a 15-year-old named Lewis Blackman. After a successful thoracic surgery on a Thursday in 2000 at the Medical University of South Carolina, the teenager was given the painkiller Toradol, which has the known side effects of perforated ulcers and internal bleeding. Because there was no room in the surgery ward, he was placed in the children's cancer ward to recover. Over the following weekend, Lewis slowly bled to death internally, with his parents' concerns and his increasing pain and other troubling symptoms largely ignored or mismanaged by the on-duty clinical team of residents and nurses.
“This is the result of overcrowding,” said Dr. Litvak. Beds aren't available, so patients are placed in suboptimal beds in different units and nursing resources are stretched thin. Hospitals become really full on Wednesdays and Thursdays [the day Lewis had his surgery], and then there were no surgeons or other experienced physicians around over the weekend to identify what was happening.” This problem and Lewis Blackman's story prompted him to submit an op-ed, “Don't Get Your Operation on a Thursday,” to The Wall Street Journal, which was published in December 2013. (http://on.wsj.com/14RE1BW.)
----------------

1 comment:

Anonymous said...

AND THINGS ARE GETTING MUCH WORSE

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