Across the country, emergency departments (EDs) are overwhelmed. There are many reasons for the overcrowding. It is estimated that 44 million Americans have no health insurance and have no other place to go for care. Decreased access to office and clinic physicians has driven more patients to emergency departments. Lack of inpatient beds often translates into long delays for patients who need to be admitted. The list goes on.
On the positive side, EDs do provide an attractive revenue stream, particularly when there are charges for imaging services. Revenue is also enhanced indirectly through increased hospital admissions. At Florida Hospital, East Orlando, almost 80% of inpatient admissions come from the ED.
It is imperative to get patients in and out of the ED as quickly as possibly to maximize the revenue potential. Also, customer satisfaction is closely tied to the length of time from diagnosis, to treatment, to transition out of the ED.
The wait for plain film imaging is one of the four main bottlenecks in the ED process, along with the wait to see a physician, obtain laboratory results, and admit inpatients to a nursing unit. Radiology departments generally wage a daily battle responding to stat requests for testing from intensive care units, surgery, and the emergency department. Attempt to balance that with scheduled outpatients and what results is a recipe for delays and unhappy patients, physicians, and staff.
If the premise that emergency patients are a good revenue source is accepted and that patient satisfaction is critical, it makes sense to ensure that radiology is not a bottleneck in the emergency care process. The following example illustrates time savings of 5,000 hours per year to the ED and its patients when the radiograph turnaround time is reduced by 15 minutes or 38%.
Florida Hospital?s Experience
Florida Hospital, East Orlando is a 108-bed hospital with a 21-bed ED plus an 8-bed Express Care area. The ED saw about 50,000 patients in 1999. The radiology department includes four radiographic rooms, performed about 42,000 procedures in 1999, and is adjacent to the emergency department. With just four radiographic rooms, equipment capacity is at a premium. The ED faces the same challenges as many across the country: overwhelming demand, not enough capacity, and unhappy customers.
In 1998, the hospital began looking at the ED process. One of the first questions to answer was the length of time it took to complete a study. It was easy to raise the question, but in reality no one had any idea how long it took. The first step, as it always is, was to measure the turnaround time. The time radiology logs an examination complete minus the time an order is placed by the ED was measured.
Initial results averaged 40 minutes per patient. Improvements generally did not require capital or more staff, and we had to make sure they did not come at the expense of service to other customers. We shared results with staff and determined a target for ED turnaround with their involvement. Our first target was 30 minutes. In 1999, we lowered the goal to 25 minutes. This was achieved in the fourth quarter of 1999.
How Improvements Were Made
Measurement, goal setting, and constant communication resulted in some improvement. Communication included reporting to an ED task force at department meetings, with results posted in radiology. ED turnaround was added to everyone?s performance expectations, from director to technical staff.
While getting a radiograph was often a bottleneck in the ED process, the bottleneck within the radiology department was a high rate of radiographic equipment utilization. Four rooms for 42,000 outpatients, inpatients, and ED patients did not seem adequate. Adding equipment was not an option. The objective became to do anything it took to keep the rooms occupied with patients. For example, when demand increases, radiographers are now kept in the radiographic suites while other staff transport patients, hang films, and answer phone calls.
Performance was graphed based on the time of day an order was generated for service. This allowed us to identify time frames where an adjustment in staffing was needed. Staffing hours were increased during time frames where the standard was not being met. Hours were decreased during other time frames. These changes did not result in a staffing increase. The department?s productivity has improved about 7% measuring examinations per hour worked.
The department created a manual work list where orders of all types — inpatient, outpatient, unscheduled, and emergency — are placed in slots on a board. Orders are prioritized on a first come/first served basis. ED patients have no priority over anyone else, unless someone is in critical condition. In addition to keeping orders prioritized, the work list is a billboard notifying everyone of how much work is waiting to be done. Additional resources can be summoned if the work list gets too long.
Minor Process Changes.
Process changes resulted from analyzing turnaround times that were greater than 30 minutes. When a procedure took more than 30 minutes, we looked for reasons and ways to decrease that time. Many of these changes were minor. Added together, they made significant improvements. For example, the two radiographers staffed at 5 am would both go to nursing units to perform early morning portable examinations. ED patients waited until they returned. When the problem was shared with staff, they solved the problem by asking to be paged for emergency examinations during that time frame.
Radiographs on Multiview.
All radiographs are placed on a multiviewer in the ED where a emergency physician can review them before a radiologist provides a final reading. A radiologist periodically goes to the multiviewer and reads ED images throughout the day. This process has been in place for many years and contributes significantly to quick turnaround.
Dedicating a radiographer to the ED is not an option that works well for us, but is a good idea in departments where there is a radiographic room in the ED, remote from the main radiology department.
Providing quick turnaround for ED patients does not require high technology solutions. It does require measurement, goal setting, and constant focus on improvement. The result is that more patients get into the ED; they also get out, quicker and happier. As a result, our radiology department generally rates higher than any other indicator of ED patient satisfaction at Florida Hospital, East Orlando.
Lester Rilea is director, Department of Radiology, Florida Hospital, East Orlando.