Ways to Create Better ER Experiences for Patients and Clinicians

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Although patient volumes can be unpredictable in the ER, flow tracking creates a baseline for change by highlighting where the bottlenecks are. When tracing patient flow from the front door to discharge, primary areas for analysis at each stage are how your hospital educates, communicates, and adopts modern technology, all of which have an impact on both patient and provider experience. Two additional factors to monitor when evaluating patient throughput is the amount of time and the number of paper forms required at each stage of care.

3 Steps to Measure Patient Throughput in the Emergency Room

1. Build an improvement team

If a patient walks in to the ER unannounced as they commonly do, they may not think about pre-registering–or even know that is possible. When a patient approaches the front desk, they expect immediate attention. Instead of registrars giving out numerous paper forms filled with redundant demographic fields and unnecessary questions, they could provide a tablet or QR code so the patient can complete eForms from the comfort of their own device. This decreases exposure time and stress and allows hospital staff more time to engage with patients.

Eliminating paper with the implementation of Access eSignature platform solutions saves time and money, and patients are happier when they can utilize their iPhone to electronically sign and complete eForms. Access solutions upgrade the patient’s experience by giving patients the ability to choose a registration process that they are most comfortable with and engage with the hospital more seamlessly. With Access, patients could complete medical forms inside or outside of the ER, freeing up staff to prioritize care and not paper.

In terms of cost savings, consider how much paper forms cost your hospital. An annual patient volume of 350,000 with an average of 23 forms per patient visit would result in an annual paper volume of 8,050,000. Access’s eSignature solution provides a 22% average reduction in paper usage, which, at a rate of $0.10 per page, would amount to annual cost savings of $175,000. If you would like to calculate a personalized ROI for paperless registration based on the specifics of your hospital, click here.

Refine EMS-ER Communication Through Standardization

Not every ER patient is ambulatory and may be transported to you by Emergency Medical Services (EMS) personnel. After EMS hands over their patient to the ER, there are many questions that they ask themselves: Did I do enough? Did I perform the right care? Was there anything I missed or failed to pass along to the Emergency Department? What could I have done better? These are all valid questions that can trouble an EMS provider after a call. The best way to ensure that you have done everything to provide continuity of care is to maintain accurate and complete documentation and confirm that the hospital receives that information. Below are a few examples of practical ways to create better handoff procedures from the ambulance to the ER bed.

Improvement suggestions for a stronger handoff

• Enact a standardized transition protocol for EMS to deliver consistent and complete patient information to the Emergency Department upon arrival.
• Dedicate at least one ER staff member to actively listen to the EMS handover.
• Relay the patient report taken from the staff promptly to the appropriate ER provider.
• Invest in EMS technology that connects pre-hospital information, such as EKG and vital signs, to be fully interpretable by ER providers as the patient is rolling into the hospital.

Enhancing EMS-ER communication requires ongoing evaluation of current processes and workflows. Variability in communication methods is a barrier to exhaustive patient care in moments of crisis. Creating standard operating procedures establishes a work tempo and clear expectations for all staff. Delineating these expectations allows for EMS personnel and ER staff to ask the right questions when answers are not clearly communicated before it is time for the ER provider to begin their evaluation of the patient.

 Speaking to patients in layman’s terms about the healthcare process provides the peace of mind necessary to begin building trust in the provider-patient relationship. The AIDET (Acknowledge, Introduce, Duration, Explain, Thank) protocol is a tool to give medical professionals a framework for conversation when addressing patients and families. This process brings clarity to the patient, reassurance to the families, and standardization across different providers. The AIDET method also decreases patient anxiety and is critical for building trust in the provider-patient relationship, leading to improved quality of care and higher HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores.

A cross-sectional study involving 764 patients and 327 physicians demonstrated that 35.1% of patients prefer to have the last word in clinical decisions. Patients need clear and comprehensive information to make an informed healthcare choice. Below is an example of how to maintain consistent communication to equip patients with the guidance they need to select the appropriate course of action. 

Patient communication in the emergency room is imperative for everyone involved. Hospitals cannot start making improvements in communication without the institution of a written directive. Although a short acronym is not an exhaustive solution for complete communication, AIDET provides a foundation. While AIDET can serve as a building block to establish a standard in your practice, constant reevaluation will be necessary to adapt these protocols to best suit your hospital’s needs.

Depending on the clinical decision from the doctor within the ER, the patient could be admitted to the hospital for further treatment, sent to the OR for surgery, or discharged if no further treatment is needed at that time. The two critical friction points during this transition are complete communication from the ER staff to the receiving providers if a patient is being admitted and obtaining consent if they need surgery.

Enhance Patient Handover Communication with the SBAR-DR Format

The SBAR (Situation, Background, Assessment, and Recommendation) approach can assist during the transition of care. Originally used by the United States Navy as a form of communication on submarines, the format was adopted for hospital communication at Kaiser Permanente in 2003, structuring conversations between doctors and nurses for cases that required immediate action. Although the original intent was for acute cases, this model quickly spread to all areas of the hospital, as it increased accurate handoffs and resulted in higher satisfaction among providers. One study used a modified SBAR-DR strategy to assess physician handoff conversations 60 days prior to and 60 days after applying the new strategy. Below is the framework used for conducting the handoffs in this study.

SBAR-DR Format for Handover Communication Between ED & Admitting Physicians

Situation: Identify yourself by name, rank, and department. Then identify if the patient is a new admission or just asking for a consultation. Then state the working or differential diagnosis.

Background: Identify the patient while also providing relevant history, medications, exam findings, vitals, and test results.

Assessment: Determine the severity of the patient’s condition with a timeframe. What treatments were done in the ER and did this make the patient’s condition better or worse?

Responsibilities & Risk: What tests or information is pending and who is responsible for providing those details? Are there any risks for this patient?

Discussion & Disposition: Open the floor to questions from the incoming provider and determine ED admission.

Read-back & Record: The admitting doctor repeats the information back to the ER. The emergency physician will also need to provide a written handoff prior to conducting the verbal handoff.

After completing the study and collecting all the data, two blinded physicians used a 16-item scoring sheet to rate the transcriptions from the conversations. In addition, a post-intervention survey was given to the physicians involved in the study. The results conveyed a 12.1% increase in time for questions and 20.9% increase in confirmations of the disposition plan. Additionally, the survey showed that many emergency and internal medicine doctors felt that the SBAR-DR framework had a positive influence on patient safety and handoff effectiveness.

Clear and complete communication is a life-or-death matter in every emergency room. A breakdown in communication can lead to misinterpretation and mistakes—at a great cost. From 2009-2013, communication was a factor in 30% of 23,658 medical malpractice cases, leading to $1.7B in total losses. Searching for pragmatic solutions to increase the accuracy of communication is vital to protecting patients and staff in the complex environment of an ER.

Eliminating Emergency Room Paper Informed Consent Risks with eConsent

The second major friction point is obtaining a consent signature from a patient and then getting that document indexed without misplacing it in the process. A JAMA Network study showed that 14% of operative cases were delayed because of missing signed consent forms. The average cost of a lost minute in the OR is $60. Suppose your hospital has an annual procedure volume of 15,000 with a conservative estimate that 7% of procedures are delayed. If each procedure is delayed for an average of 15 minutes, that would add up to 15,750 lost minutes in the OR, or a loss of $945,000 per year, all because of a misplaced consent form.

A vital part of the discharge process is providing information that enables patients to be better stewards of their health once they leave the ER. Ongoing health education is critical with less patient confidence in the healthcare system, lack of communication from providers, and general distrust of medications and services. To meet the expectations of patients, The MS Center of University Hospital Basel, Switzerland, started a nurse-led evidence-based patient education program to address the need for patient education before, during, and after treatment. In 2015, a pre-test/post-test design was conducted on 98 people with Multiple Sclerosis (MS) at the MS Center by conducting before and after educational sessions about fingolimod treatment. The purpose was to evaluate the subjective perception of being informed about the treatment, self-efficacy in handling it, and satisfaction with the program. The information talk was composed of six main topics written in simple terms.

ED Informational Talk Outline

• How it works (efficacy and mode of action)
• How to take it (all aspects of administration, pauses and non-adherence)
• How to store it and how to travel with it
• How to get it (pharmacy, costs, and insurance)
• Potential side-effects and how to understand the patient information leaflet
• Safety issues, risks and their prevention, and monitoring over time

The content discussed during the ER informational talk was placed on text cards accompanied by pictures to assist the patient in fully understanding the information being provided. After the talk was completed, the patient received “memory cards” along with a manufacturer’s booklet to take home. This engagement helped satisfy the patients’ information needs while increasing treatment knowledge and building confidence in the care team. This treatment education resulted in significant increases in knowledge from pre- to post-test, including a greater perception of being informed and higher levels of self-efficacy.

How to Use the Teach-Back Method when Discharging ER Patients

The teach-back method is a straightforward way to ensure that the ER informational talk engages the patient with the instructions by reexamining the relay of information. After discussing the treatment, the disposition, and follow-up instructions with the patient, the patient then “teaches” all the information back to the medical staff in their own words to ensure complete transfer of information. This allows an opportunity to identify and fill knowledge gaps and reinforce understanding by expanding on relevant details.

The Journal of Emergency Medicine published a study in 2017 that examined the relationship between the teach-back method and retention rates in post ED discharges. Post-discharge patients were asked a series of questions over the phone and then scored based on their ability to recall information about their diagnosis, medication reconciliation, follow-up instructions, and return precautions. The patients that were engaged in the teach-back method scored 15% higher than the patients in the pre-intervention group. This method is a simple way to improve patient comprehension while using communication as a prevention tool against high ER patient volume.

In 2018, the St. Claire Regional Medical Center in Morehead, KY conducted an exploratory study of a lay-health worker (LHW). A LHW serves as the link between hospital health services and the community. The goal is to assist patients in the transition of care from hospital to home. The LHW helps patients with psychosocial preventative interventions, behavior modification, shared decision-making, health education, and how to use health resources. Additionally, the LHW, guided by The Wellness Needs Assessment (WNA), conducts anxiety and depression screenings. To gather a complete picture, social considerations such as transportation, housing, community safety, home safety, and financial barriers are also included as part of the patient and LHW interaction. The study, aimed at analyzing hospital readmission rates over a 30-day period, found that the LHW had a marginal impact on the general population but was remarkably effective in reducing readmission rates on high-risk patients.

High-risk patients with similar demographics and health disparities had a 56% decrease in odds of being readmitted after they had gone through the LHW program.

The coordination of the LHW and case manager in addressing the patient’s self-identified and social needs allowed the hospital staff to assist the outgoing patient with some of the underlying factors that caused readmissions in the emergency room.

Another study conducted by the Journal of General Internal Medicine in 2014 examined the effects of the relationship between a care transition intervention and cost reductions after hospital discharge. The study included fee-for-service Medicare beneficiaries that were hospitalized over a two-year period in six Rhode Island hospitals from 2009-2011. One group of beneficiaries received patient-centered coaching to take ownership of their care, which included one home visit shortly after discharge and two or three follow-up telephone calls during the 30-day discharge period. The group of patients that received the intervention had a health care cost savings of $3,752 over a six-month period compared to the group that did not receive any intervention after discharge.

Both these studies highlight how education can be an effective tool to provide comprehensive medical care that serves patients ailments and wallets to ensure that they remain out of the ER.

1. What happened during the event?
2. Why did it happen?
3. How can we sustain strengths or improve on weaknesses?

The questions are simple, but they provide the necessary framework to help drive protocol changes, recognize gaps in training, and improve communication during future events. The AAR model can be used to create a debriefing process that fits the needs of your emergency department. The Cambridge University Press published a paper in 2018 evaluating the use of the INFO (Immediate, Not for personal assessment, Fast facilitated feedback, Opportunity to ask questions) clinical debriefing process by equipping charge nurses with the tools to address two fundamental issues: a lack of trained facilitators and a focus on physician-led debriefs. Charge nurses were identified as the individuals in hospitals that have the knowledge and awareness to best facilitate briefs on a regular basis.

Alleviating pressure from physicians to conduct these briefs generates consistent communication among staff in the ER and allows for continual improvement without sacrificing patient care. Effective conversation post-ED events are the driving force of a tenable ER.

Educating and engaging the community by discussing different options can help alleviate pressure in the emergency department by empowering patients through outreach programs such as community-based participatory research (CBPR). CBPR is all about involving people in the community by helping them identify and define their health problems. This long-term approach includes co-learning, shared decision-making, mutual ownership of research findings, and dissemination of results. The partnership between hospitals and communities can help drive better health outcomes by building awareness and translating research into policy and practice.

Working to reduce emergency room patient volume requires a multifaceted approach. There is not a one-size-fits-all approach, but applying a combination of community health education, patient education, community-based participatory research, employing lay-health workers, and implementing holistic care teams are all practical solutions to reduce the endless stream of patients. Emergency department volume is volatile, but patients are adaptable if an education plan is in place to address concerns and equip them with answers before they have questions. Treatment is a temporary fix for an acute patient, but education is a chronic solution.

Educating and engaging the community by discussing different options can help alleviate pressure in the emergency department by empowering patients through outreach programs such as community-based participatory research (CBPR). CBPR is all about involving people in the community by helping them identify and define their health problems. This long-term approach includes co-learning, shared decision-making, mutual ownership of research findings, and dissemination of results. The partnership between hospitals and communities can help drive better health outcomes by building awareness and translating research into policy and practice.

Working to reduce emergency room patient volume requires a multifaceted approach. There is not a one-size-fits-all approach, but applying a combination of community health education, patient education, community-based participatory research, employing lay-health workers, and implementing holistic care teams are all practical solutions to reduce the endless stream of patients. Emergency department volume is volatile, but patients are adaptable if an education plan is in place to address concerns and equip them with answers before they have questions. Treatment is a temporary fix for an acute patient, but education is a chronic solution.

The World Health Organization defines burnout as chronic workplace stress that has been unsuccessfully managed. Symptoms include exhaustion, distancing from the job, and reduced motivation. Emergency room providers are especially susceptible to burnout, particularly due to the extreme stress of the COVID-19 pandemic. Clinicians are working longer hours to try to reduce ER patient volume but receiving inadequate support, leading to increased tensions inside emergency departments.

Causes of Burnout

In 2018, the American Journal of Medicine published results from an online survey of 15,000 U.S. physicians in which 42% of providers reported burnout. The reasons for burnout included the adoption of new electronic systems, reimbursement pressure, and a reduction in providers feeling fulfilled in their work.

The University of Illinois published a research article in 2020 that surveyed 2,707 healthcare professionals from 60 countries to study burnout during the COVID-19 pandemic. Their report showed that 51.4% of the professionals from 33 countries reported emotional exhaustion burnout during their work. The United States topped out the list with 62.8% of healthcare workers reporting burnout, a 20% increase from pre-pandemic levels. Factors that contributed to the increase in burnout included more work hours, higher stress with continued care of critical patients, work affecting their capacity to complete household tasks, and a lack of satisfactory PPE supplies. Below are additional frequent causes of clinician burnout in the ER.

Effects of Burnout

Burnout is detrimental to the mental health of emergency room providers. About 1/5 of physicians surveyed said that they were depressed. Among those, 24% were clinically depressed (severe depression over time) and 64% were colloquially depressed (feeling down or blue over a short time).

Improving communication in the ER is necessary to tackle the stigma of seeking help from mental health professionals. The compounding effect of depression can generate hospital-wide ramifications when burned-out is left untreated.

The scariest effect of burnout is suicidal ideation. An estimated 300-400 physicians in the U.S. die by suicide every year. Medscape conducted an online survey of over 13,000 physicians in the U.S. about burnout, depression, and suicide. In that survey, emergency medicine was among the top specialties whose providers struggle with suicidal thoughts. While the cause of provider suicide is multifactorial, burnout plays a notable role. The following chapter dives into five feasible ways to begin addressing this crisis.

1. Maslach Burnout Inventory

To determine which solutions will work best, start by collecting data. The Maslach Burnout Inventory (MBI) is the most widely used instrument to gauge burnout. The MBI is a 22-item self-reported questionnaire that looks at exhaustion, depersonalization, and personal accomplishment, which gives hospital leaders the information necessary to begin making measurable changes.

2. Chief Wellness Officer

Lasting change starts and sticks whenever it happens from the top down. Culture change in the hospital takes a collective effort, but reducing burnout requires a shift in thinking. Many hospitals have created a new position called Chief Wellness Officer (CWO), whose sole job is to promote initiatives to take care of hospital staff. This position paves the way for a strong wellness program and shows ER personnel that their well-being is a top priority.

3. Ambulatory Process Excellence System

The Ambulatory Process Excellence (APEX) focuses on leveraging trained medical assistants to alleviate the administrative burden on ER providers. Initial patient interaction starts with the medical assistant obtaining health data, setting the agenda for the visit, and identifying preventative care options. All the collected information is presented to the clinician to facilitate a focused exam and allow for higher quality care. Once the provider is finished, the assistant will provide additional education and health coaching as needed. This model frees up the clinician to spend more time doing what they do best and less time on administrative tasks.

4. Time Bank

Not all motivators are created equal. Productivity-based compensation can lead to overworked ER providers, and it incentivizes spending less time with each patient. Alternative methods of compensation could foster an environment that encourages engagement while improving work-life balance. Stanford University tried a “time bank” program to reward clinicians that spent time outside of their normal scope by serving on committees and other engagements. This program gave providers the ability to trade that time for support such as meal delivery, cleaning services, and assistance with grant writing and submission. The program reported that the feeling of being supported nearly doubled at the end of the initiative.

5. Mindfulness-Based Stress Reduction Program

The Mindfulness-Based Stress Reduction (MBSR) program focuses on reducing stress and coping with emotions through mindfulness meditation. This eight-week behavior program promotes metacognition and slowing down to become conscious about how the world is experienced through the senses. Components of this program could include meditation, body scanning, and yoga. All these activities can assist in developing work conditions that improve self-awareness, reduce stress, and curb the depersonalization that occurs from ER burnout.

Chronic workplace stress thrives in the absence of persistent and adaptable solutions. Although the pace of an emergency room will always generate varying levels of burnout among providers, there are effective means for organizational intervention.

Conclusion

Our ability to communicate our concerns, our thanks, and our humanity is necessary to build a flourishing ER that sustains the work of healthcare heroes and provides the optimal experience for patients. Effective communication and education should be the common thread through every provider-to-provider handover, nurse-to-patient conversation, clinical debrief, and patient family interaction.

Access eForms provides interoperability within various EHR’s that connect all stakeholders in the healthcare ecosystem that ensures everyone has the most up-to-date information about the patient. This also allows for real-time collaboration and decision-making, which can help avoid potential complications like a missing consent form or bottle necked registration department. A registration department riddled with costly paper forms creates major headaches and cost inefficiencies. At Access, we’re here to help you solve your most pressing problems so that you can focus on what matters most.

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