Inland Empire Hospitals Get Creative To Cope With Busy EDs

As the number of patients seeking care at emergency departments has escalated in recent years, hospitals in the Inland Empire have turned to experimenting with creative techniques in an attempt to decrease wait times.

Those strategies have varied from developing fast-track systems that rely on rapid medical evaluations for walk-in patients to adopting online check-in systems and offering text messaging services that alert patients about wait times. A few Inland Empire hospitals have even taken to the freeways to advertise these new services on giant billboards. One hospital’s roadside advertisement displayed estimated wait times in comparison to other hospitals

James Lott, Hospital Association of Southern California executive vice president, said developments in the Inland Empire mirror what is being seen throughout the state’s southern region. Hospitals are adopting new approaches to cope with the dramatic rise in patient volumes, he said.

“There is a dearth in capacity,” Lott said. “Hospitals are doing all of this to reduce the clogging up of emergency rooms by patients who don’t really need to be there.”

Some of the most common techniques include performing aggressive screening when patients arrive at EDs, setting up urgent care centers, and partnering with community clinics and outpatient centers to provide treatment for patients who don’t have emergency needs.

Another trend is having patients register online and wait at home rather than in an ED.

New Fast-Track Systems

Arrowhead Regional Medical Center in Colton, San Bernardino County, had the busiest ED in the state in 2008, according to the latest data available from the Office of Statewide Health Planning and Development. It was one of the first hospitals in the region to implement a fast-track program, a system developed by hospital staff when they realized ED volume had doubled in less than five years, said Jorge Valencia, ARMC spokesperson.  

On average, Arrowhead’s ED handles 400 visits a day. In flu season, that number can rise to close to 500.

“It’s best to get them through as quickly as possible,” Valencia said. “When you have people who are waiting so long, they tend to get tired of waiting and go home, and they don’t have their particular issue resolved.”

On a recent morning at the medical center, walk-in patients were first screened by a registered nurse stationed at the ED door.

Half the ARMC ED has been converted into pods with cubicles where providers meet with patients to take their vital signs. On this day, three registered nurses, two attending physicians and two physician assistants manned the pods. The number of providers on the floor can be adjusted depending on patient volume. 

Once the patients have checked in, they are ushered into one of the six cubicles. After meeting with a provider, patients sit sitting in the waiting room area for test results or a prescription.  

On their way out, patients can stop at a separate area where they can ask questions about their insurance. The through-time for non-acute patients is 80-90 minutes.

Rodney Borger, chair of ARMC’s ED, said that the system helps sort out the most acute cases so they can be treated first. Those patients are sent immediately to beds in the back of the ED. 

Since the new system was implemented at ARMC, approximately 25 hospitals have visited the center to observe the rapid medical evaluation process.

“No one had ever done it on such a large volume before us,” Borger said.

New Technologies

In July, Loma Linda University Medical Center started using InQuickER, a program that lets patients with non-life- or limb-threatening emergencies go online to schedule an ED visit. Hospital administrators say the program eliminates the uncertainties of waiting in the ED waiting room by scheduling a time to come in to the ED.

“What really distresses patients that come to the emergency room is the unknown,” said Robert Steele head of the medical center’s general emergency medicine division, who spearheaded adoption of the online service. “They show up. It looks busy, and we have a difficult time quantifying how long they are going to wait.”

He added, “It creates a realistic expectation that we can meet, an expectation that they are going to come in and have an assigned time.”

But the service isn’t free. There is a $24.99 fee to access the online site. The hospital hasn’t received any complaints about the fee, said Herbert Atienza, Loma Linda University Medical Center spokesperson.

The online program is one of several strategies Loma Linda University Medical Center has employed to manage its ED volume.

“We’ve seen a dramatic uptick over the last three years,” Steele said. “Sometimes we are the only access to care.”

In a process similar to Arrowhead Regional Medical Center, a nurse practitioner stationed at Loma Linda’s emergency entrance performs a rapid medical exam when a patient arrives. If the patient doesn’t need to be brought back to a bed, a nurse will take down the patient’s information and history and perform a physical exam. At that point, a decision will be made about labs and radiographs and a workup will be started immediately. A similar system is also employed at Kaiser Permanente Medical Center in Riverside.

In an effort to become more efficient and further speed the process, Loma Linda University Medical Center has switched over to electronic health records and scribes take down dictation as doctors visit patient bedsides. The ED also employs nurse-initiated protocols to help when there is a bottleneck.

“What we’ve done is go after bottleneck after bottleneck,” Steele said. “And what we’ve found is that once you fix one bottleneck, you find another bottleneck.”

Two Patient Populations

Christina Bivona-Tellez, Inland Empire regional vice president for the Hospital Association of Southern California, said online check-in systems help hospitals cope with two very different patient populations — those who have life-threatening or acute emergency needs and those who don’t have acute conditions, but either lack insurance or are enrolled in Medi-Cal and have nowhere else but the ED to seek treatment. Medi-Cal is California’s Medicaid program.

“I think for some groups of patients that it’s great for them,” she said of Loma Linda’s online check-in system. “It’s almost like calling up for a reservation at a restaurant. I think they’re trying to satisfy different populations who have different comfort levels.”

Borger, the emergency doctor at Arrowhead, questioned whether the online appointment centers actually fulfill an ED’s mission.

“You’re getting preferential treatment, when that’s not how emergency departments are supposed to work,” he said. “You’re supposed to get treatment based on how sick you are.”

Proponents of the online check in system say the program helps to prevent overcrowding, by spreading patient visits out over the course of an afternoon or evening.

“Instead of having 10 people show up at 11 o’clock at night, I now have the opportunity to put one at eight, one at nine, one at 10 … so I can spread out that surge that comes in,” Steele said.

Tackling ED wait times has become the charge of many hospitals in the Inland Empire’s western region, where population density is the greatest.

In May, Riverside Community Hospital adopted a text messaging system that lets patients know how long the wait time is and provides a phone number to speak with a nurse.

St. Bernardine Medical Center in San Bernardino recently restructured its ED and implemented a fast-track program that helped to manage a rapid increase in its number of patients.

Like Loma Linda, San Antonio Community Hospital in Upland also uses scribes who take notes while the doctor visits with a patient, Bivona-Tellez said.

“That’s a more unusual strategy that isn’t employed elsewhere, but they say it has made a huge difference,” she said of San Antonio Community Hospital.

Rising ED volumes

Experts say there are a number of factors contributing to the spike in ED volume in the Inland Empire. A large number of the patients seeking ED treatment are enrolled in Medi-Cal.

“Many of those patients aren’t able to go to their urgent care centers because Medi-Cal doesn’t pay for those,” Bivona-Tellez said.

Patients who are uninsured and can’t afford to pay a doctor’s fee are also going to EDs for treatment.  Hospital EDs are required by federal law to treat whoever shows up at the door, regardless of the patient’s insurance coverage or ability to pay. Overall, more than one million Inland Empire residents do not have insurance, according to a study by UCLA Center for Health Policy Research.

In addition, there is a shortage of primary care physicians in the Inland Empire, so patients with complex cases who used to get seen at a physician office are getting referred to the ED because physicians don’t have time to do a thorough evaluation, Borger said.

Lott said ED capacity hasn’t kept up with demand.

“In the Inland Empire and elsewhere, we simply don’t have the supply for emergency room capacity that we need,” he said. “Demand is increasing and capacity is remaining static, and that results in there being greater clogging — and greater wait times for people who don’t have emergency situations.”

Experts said that having more urgent care centers in the area would help alleviate the strain on EDs.

“Our challenge is we’re under-doctored, we’re physician-extended, we don’t have enough hospital beds,” Bivona-Tellez said. “It’s one-stop shopping if they go to the emergency department, and they get all their tests and medication done in one fell swoop.”

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