Excessive wait times at VA hospitals have become front-page news. It is a complaint that I am very familiar with as a physician who has worked in the emergency department (ED) for a long time. And although the problems uncovered at the Phoenix VA Health Care System (where I currently work) and other health care centers involve bringing new patients into the system, not the hours spent waiting in the ED, our experience trying to reduce wait times may provide useful lessons as the VA seeks to reduce the backlog and see all its patients in a reasonable amount of time.
Overcrowding and long wait times are hardly unique to VA EDs, these are problems faced at most large hospitals. Today, the increasing use of the ED is driven by patient demand, changing benefits (insurance/entitlements), and shifting expectations. Many patients in the ED for nonemergent care do not have regular primary care providers. Others may be turning to the ED because of difficulty getting appointments to see a primary care provider. Some patients simply use the ED for convenience (it is open 24 hours a day after all) and because there are no copayments.
Emergency department providers have made many attempts to address wait times and overcrowding; however, these problems are complex, caused by rapidly shifting bottlenecks, making simple solutions challenging and difficult to resolve. Seemingly rational interventions aimed at reducing the wait times are frequently unsuccessful, a result of a rapidly changing and dynamic environment—you are only as fast as delays allow.
IDENTIFYING BOTTLENECKS
Capacity issues can cause bottlenecks in the ED and lead to overcrowding. The capacity of ED resources can vary widely over time. For example, radiology capacity at night depends on the radiology technician on call and how far the technician lives from the hospital (if there is no 24/7 in hospital coverage). Often, external issues can cause problems, such as if the clinics at the institution are closed (for federal holidays at the VA, for example); there is a primary care staff shortage (a nationwide problem); scheduling issues; or the clinic staff are in mandatory meetings. In these instances patients may directly or indirectly get diverted to the ED, slowing its flow.
Similarly, responsiveness or availability of specialists to offer consults can contribute to the time spent in the ED. In addition, the delay in getting patients into a hospital bed after being admitted can sometimes take many hours, tying up the already limited bed availability.
Physician and nursing capacity is even more complicated, because the volume of patients at any one time is unpredictable. Emergency department physicians have a variety of backgrounds and different skill sets; some can process patients more efficiently than can others. And the chemistry among the various staff working on a given shift can also shape capacity. Good team chemistry helps an ED work efficiently.
The demand placed on ED resources also varies, based on the patient mix over time. There are days where seemingly everyone needs a CT scan, which creates a bottleneck. There are other days when it is a trauma day when the X-rays and radiology techs rapidly get backed up. Then there are times when the CT scanner or MRI is down, or other technology issues create delays. All ED processes are interconnected. Unless you increase capacity for those days, the flow will be decreased and waste increased. Contributing further to the ED congestion is the recent trend in the health policy community and at the VA to shrink the ED resources while at the same time trying to improve patient satisfaction scores.
Many communities, like Phoenix, have seen significant shifts in veteran populations as aging veterans choose to move to retirement communities in the south and west. Even the seasonal fluctuations as aging veterans spend the winter months in warmer communities can impact the ED. Combining these trends with recently expanded eligibility standards in the VA system creates an imbalance in the flow of patients and strains the capacity at many facilities like ours. Without adjusting the capacity of the ED (and other departments) to handle more patients, setting new benchmarks to reduce veterans’ wait times is not workable.
Some EDs have experimented with streamlining processes using “lean” business management. Sources of waste and inefficiency are identified and alternate processes developed. The Phoenix VA ED has tried some of these techniques with some success. For example, we have decreased the wait times and fewer patients leave without being seen, while at the same time the patient volume has increased. We now have front-end initiation of a workup based on the presenting complaints. Thorough workups in the ED can be useful, especially if they prevent a costly hospitalization. However, these workups add to the demands placed on the ED’s precious commodity—the bed.