Why does you ER visit take so long? Take a listen as I discuss some of the inner workings of the hospital. You may be surprised as to why you have to wait.
Why does you ER visit take so long? Take a listen as I discuss some of the inner workings of the hospital. You may be surprised as to why you have to wait.
Cheers everyone welcome back to Emergency Minute Episode 4 – Why does my ER visit take so long?
So why does it take so damn long to get through a visit to the ED?
You see, processes in the ER are like just about any business model out there. To get in and out of an ER, you have the front end, processes in the middle, and backend. The analogy I like to make is a Mexican restaurant, especially because they seem to do it so well. How quickly can I be seated, then how long for my food to be prepared and brought out, and finally checkout process.
So with front end hurdles, we have the horrible, outdated, extremely inefficient triage room. Anyone who’s ever worked with me know how much I hate this concept. Why? Because imagine if a bus crashed into the hospital and we got 50 patients all at once, would we just simply create this ginormous bottleneck and only evaluate all 50 of them 1 by 1? Even if you did that quickly, say 3 minutes per patient, that’s nearly 3 hours to process and triage all 50 pts, and oh by the way, that’s assuming that no one else needs to be seen in that 3-hour window. What most hospitals do now is something called pull to full, which is exactly what it sounds like: you pull the patient back until the ER is full, and then you use the triage room. This allows for multiple nurses, medics, and staff to bring multiple pts back and make the process much more efficient.
So, this really isn’t that hard, and is the standard for how all ER’s should be run. If you go to a hospital that doesn’t do this, you may want to reconsider, as this is such a simple concept to embrace. What happens when you get brought back? Well, ideally you have bedside triage and the patient can give their history to the provider and the nurse at one time. Again, a fairly simple concept that prevents the patient from having to state their story multiple times. This doesn’t always happen with so many things happening simultaneously in the ER, but this should be the goal of your ER.
As you can see, the front-end challenges really aren’t that hard. Let’s look at issues that arise during your visit.
Much of what happens while you’re sitting in your room is beyond the control of the ED. For example, when you have bloodwork done, we have little control over how quickly the labs are resulted. And what if the machine goes down, or one of them is broken or needs rebooted, these things cause delay all the time. Then there’s radiology. How quickly is the xray/CT/US done, how long does it take to do it, then how quickly can the radiologist read the study? This is often one of the biggest delays in the ER. Like the rest of the world, the radiologists must do more and more with less and less. They are short staffed, too. Especially if you come to the ER after hours. Many hospitals use a teleradiology service that covers numerous hospitals across the country. These big services make a lot of sense for radiology so they can cover so many different places remotely; but it sucks for the local ERs because when there’s a massive delay, there’s really no backup plan. I’ve waited as long as 4 hours for a reading, and it’s not that uncommon, unfortunately.
I say all the time that healthcare is broken, and this is perfect evidence of that. The good news is that most ER docs are more than capable of reading plain film x-rays; but when it comes down to intricate findings on a CT or US, this needs to be read by a board-certified radiologist.
Then there’s the urine. God, I hate the urinalysis. It’s one of the few tests that we do that is completely dependent on the patient doing something. With blood, we just go get it. With x-rays and imaging, we just take the patient and get it done. But a urinalysis is dependent on the patient having to pee. I don’t believe in ghosts, but there must be some type of spirit that travels around to people who are about to go to the ER and makes them urinate before coming to the ER. If you’re having belly pain, just know that we are going to need a urine sample. And for the love of God, please don’t pee in a jar and bring it in. I could do an entire podcast on things patients have brought in and took pictures of and want to show me. I’m like, nope, I believe you, I’m sure you did pass a blood clot as big as a cheeseburger from your ass, I don’t need to see it. I digress.
Finally, the backend hurdles. This applies mostly to patients being admitted or transferred out of the ER. Because if you’re simply there as a “treat and street,” meaning, an injured ankle, get an x-ray, a splint and go home, the process is usually fairly simple. Most facilities don’t take that long to discharge a patient. If you want to hear more about the admit and transfer crisis, please listen to Emergency Minute Episode 2 on the boarding and transfer crisis at your hospital.
So for patients being admitted to the hospitals, It’s just a matter of calling the admitting physician (if they call back in a timely fashion), awaiting for a bed upstairs in the hospital (or if there is a bed, or a nurse to care for the patient), waiting for that room to be cleaned, having the nurses call report (if the floor nurses are available), then awaiting transport to the room. See? So simple! Haha. You can see how this is a flawed system from a lean process standpoint. This is a Swiss cheese model where any number of things can go wrong and cause delays, and by the way, have NOTHING to do with the ER. I work at one hospital (no names, please) where I typically wait roughly 1 hour to talk to a physician, only to have that physician reach out to the admitting service to call me, which is typically another hour later. So even though I could have the patient seen, worked up, labs resulted, treatment started in under an hour, I could be waiting multiple hours for a call back and multiple hours for the bed assignment, transport, etc. But what does everyone say? What does everyone remember? WHY DID MY ER VISIT TAKE SO LONG?
Now, this next part is going to be brief, as it is going to get me in trouble. But I cannot possibly talk about delays in getting patients admitted without touching upon a massive flaw in how hospitals function. And that is the role of the nursing supervisor. And this isn’t just 1 place, this is fairly universal. I refer to it as a paradigm because its something that obviously doesn’t make sense, clearly doesn’t work, and yet we do it anyway, because that’s just how we’ve always done it. You see, hospitals empower the nursing supervisors to serve as the “off valve” for the rest of the hospital. If the 3rd floor just got an admission, they won’t allow the next one to come up for a bit so the staff can receive the first admit and get them settled in prior to taking a second one. What about the ER? We don’t have an “off valve.” We can’t ever turn the valve off. The patients just keep coming in the front door and by EMS. I remember a few weeks ago when the nursing soup told me she couldn’t take another patient upstairs because of nursing ratios. I said, “what about my nurses?” “My charge nurse is charge, in triage, in Fastrack, and has 8 assigned patients, how’s that for a ratio?” But unfortunately, if you empower this position to say NO, to simply create delays on the backend, you have created a massive bottleneck that impacts the entire ER.
Now, for the sake of this podcast, I haven’t even touched upon some of the other elements of delay. What if a critically ill patient comes in? Someone who is actively dying. This truly brings the ER to a standstill. What’s crazy is that I can spend an hour trying to take care of a 6-month-old who ends up dying, only to return to my desk and see that the ER doesn’t stop. No one cares that I just coded a baby. They just care that they’ve now been waiting for an hour with no update. So now I have 20 pissed off patients, who truly had an ER delay, and I have to run around and see all of them, while explaining in as vague of terms as possible that their delay was me dealing with a critically ill patient.
As you can see, there are about 100 reasons why your ER visit takes so long, most of which not controlled by the ER. Be kind to your treatment team. I promise you they are working as hard as anyone in healthcare. We are trending in a direction that we must do more and more and more, with less and less, and less. Just like much of the world, it truly is a broken system.
But you know what? People who work in ER’s are just wired differently. My nurses are freaking BADASSES and they get it DONE. PERIOD. The rest of the hospital is allowed to shut it down, and let everything fall on us in the ER, because deep down they know we can handle it. We will figure it out. We will find a way to make sure our patients are getting the best care possible. Because that is what we do, it is who we are, it is our DNA.
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