Colleagues, Conferences, Clinical Guidelines and Communication: Collaborative Medical Practice Today

Mornings are not my favorite time of the day, but I’m finding myself in the cafeteria before 7:00 AM several days a week now. No, I’m not getting coffee before an early shift, but I am doing so before the Surgery Morbidity and Mortality or Multi-specialty conference or just sitting down with a pack of proceduralists in radiology, GI, cardiology and other specialties.

I started back at this ritual, one I undertook for several years when I first started at Maimonides because I was hearing a growing number of complaints about our practice. Several physicians complained about the number of unnecessary cardiac enzyme studies drawn at triage, another complained about the one set of blood cultures rather than two, a third complained about antibiotic selection. What’s going on here?

In addition to breakfast, I went to meetings with the complaining physicians and the Chairman of Medicine. I went to meetings with the Chairman of Pediatrics and his staff. Our COO visited with physician staff and shared his observations about the complaints. At the sessions I attended, I listened, I took notes and mostly I heard about communication. Listening to the anecdotes and recounted (one-sided) telephone conversations, I realized that our colleagues were focused on their one patient, while our attending (or resident) was often distracted by other concerns and information even when they were on the telephone. Or worse yet, the call was “intended” but never completed.

I’m not saying that the clinical concerns originally raised as the issue don’t have merit and aren’t happening. In ~46,000 adult visits and ~20,000 admissions, more than 20% over age 65, I’m sure that clinical errors have and will happen. The real problem is that our admitting physicians don’t know our emergency physician staff well enough. It is a huge medical staff with over 400 internists and we’re a group of more than two dozen, but that’s no excuse. Sure we’re distracted and constantly interrupted while working in the ED; “You chose that practice,” our colleagues remind us.

Where would you go from here? I’m interested in your ideas since as leaders and members of your practice you’re challenged to introduce your newer colleagues to long-time medical staff members.

The usual advice we’ve all taught and heard is that the relationship between emergency physician and voluntary primary care physician is formed over the patient. Certainly this was my experience. Today, with most physicians in the hospital less, the telephone has become more important, perhaps we should train our emergency physician staff for telephone communication.

One thing I see, is as hospitalist practices develop and solo and small group practices diminish in number, my emergency physician colleagues are focusing on those physicians they see the most. Perhaps this is an artifact of our community teaching hospital and those of you practicing in non-teaching hospitals continue to see your primary care colleagues regularly. I’m sure diverse practice environments and hence professional relationships with colleagues foster different approaches to the problem.

We’re going to use the regulator’s growing evaluation of adherence to practice guidelines as one tool for improving communication. I’m not quite clear on the details—in fact we’re still working them out—but reminding colleagues of the JCAHO “Core Measures” for pneumonia (Figure 1) which includes evaluation of the timing of antibiotic administration allows us to put the emergency physician on the same team as the internist who is charged with assuring pneumococcal and influenza vaccination among other requirements. It will also present an opportunity to suggest that if they prefer a different antibiotic, they need not continue the antibiotic we’ve started—a choice we make using our infectious disease division’s recommendations as built into our ordering pathway.

I’m hoping that we can pull together a joint conference on the combined emergency department and inpatient management of the several core measure related disease processes we care for together: pneumonia, myocardial infarction and heart failure. Discussing our processes may enable learning that can improve the way we work, but will at least develop an appreciation for the difficulties we each face in our own clinical milieu.

With these efforts we’ll have precipitated a discussion around clinical pathways which is a pretty good place for physician colleagues to start learning about each other. Certainly it will be more productive than arguing over the timing of calls for notification of patient admissions.

If you’ve been coping with similar challenges I’d love to hear from you. Please share your problems and solutions with me by email and I’ll share them with all readers if you’ll let me.

In the meantime, I expect I’ll be dragging myself to surgical morbidity and mortality conference on Friday mornings at 7:00 AM for many years to come.

Figure 1. Pneumonia Core Measure as of April 2004

  • Oxygenation assessment
  • Pneumococcal vaccination
  • Blood cultures
  • Adult smoking cessation advice/counseling
  • Antibiotic timing
  • Initial antibiotic received within 8 hours of hospital arrival
  • Initial antibiotic received within 4 hours of hospital arrival
  • Initial antibiotic selection for PN immunocompetant – ICU
  • Initial antibiotic selection for PN immunocompetant – Non ICU
  • Influenza vaccination

Incentive Compensation and training residents. How shall we manage the intersection? (Part 2)

Last month I told you about the economic challenges we were confronting out of the transformation of our practice into one with both clinical and academic missions. I wrote about our charting improvement initiative and engaging concerned staff colleagues in both developing solutions and seeking the engagement of the broad group in the implementation of the solutions. I’ve promised that this month I would discuss modifying incentive structures so that an academic mission can be explicitly accommodated. Let’s consider some relevant observations.

As long-time readers know I have a bias towards quantitative evaluation whenever possible, thus, the recent publication[1] of a relative value scale for teaching gives me some hope for including more quantitative evaluation of teaching contributions among physician staff; however, this tool alone, even fully implemented as described by the authors probably won’t serve as the sole measure for academic productivity. Aside from my general reluctance based on Deming’s warning about management on numbers alone (see my July 2003 column) in the case of teaching and scholarly activities, how shall we assign value when the work done benefits the worker—the teaching physician—too?

Just as maximizing revenue isn’t unique to clinical practices—as an emed-l poster commented, “academic programs in particular, considering the payer environment most of them are in, need the clinical production efficiency every bit or more than the community ED.” referring to using RVUs as the driver for all compensation. Yet, in a double coverage ED, the process of supervising residents, particularly supervising senior year residents who are themselves overseeing the work of more junior residents, I would accumulate many more RVUs/hour worked than a physician in the same ED just seeing patients. Since the other physician’s work indirectly facilitates me spending time with the residents and accumulating their RVUs, some adjustment is probably appropriate to fairness.

In the context of direct teaching activity, while Khan and colleagues’ approach shows some merit, as another poster has opined in the past, “One must have adequate protected time (which is quite expensive) to further the department’s goals. Someone who runs the department, runs the residency, runs a course in the medical school, directs the research for the department—all of these need protected time. I’ve seen papers published about how protected time is counted, and am quite shocked, to be frank, that attendings are given (paid) protected time to attend (not teach, just attend) resident conferences and faculty meetings. Not that I don’t think they shouldn’t attend. But, if you have to divvy up for every minute that your faculty member spends beyond strictly clinical hours and reward it with paid protected time, you’re paying out hundreds of thousands of dollars a year just to have your folks come sit in a room, with little to show at the end of the year. It is crucial that protected time unfunded by outside resources be used wisely, if we hope to progress as a specialty. If you have to ‘spend’ it for every minute outside of a clinical shift, nothing will be left for the larger stuff, like having a productive department as a whole.”

This colleague works where the group has come to a common understanding, where certain duties are “just part of the deal . . . there were some irreducible contributions as faculty which would not be measured against ‘protected time’. This included attending faculty meetings, grand rounds, and being asked to give a talk on some subject every month or two, if needed. It may also include participation in hospital and medical school committees.”

You might argue that we should be separately compensated or supported for all of the non-clinical activities and that’s a nice idea but not reality at our hospital or in the academic environments I know. I don’t think full support for academic activities exists anywhere; that corner of our society is still a bit of a social welfare state.

So taking all these inputs together, I’ve chosen to consider the issue along the lines of the “Leading Beyond the Bottom Line” principles I’ve written about, adapting these principles first articulated by American College of Physician Executive authors.

It seems to me that our developing clinical and academic department should strive for the pareto optimum among patient care, community service, organizational economic well-being, staff well-being (economic, professional development and others) and unique to the academic environment, a fifth good: academic accomplishment (perhaps measured through RRC approval, peer academic recognition, scholarly productivity including grant funding and others as per Khan). I don’t believe that it is possible to divorce clinical center productivity from the rest and optimize it alone. We teach residents from almost every specialty, a significant fraction of patients admitted in most teaching hospitals come through the ED, we teach medical students, etc. These academic interactions matter in our institutional standing, and for those at the medical school seeking promotion and tenure (hence compensation) and other tangible and intangible aspects of life in our clinical and academe.

I still think we’re in an era of “local solutions.” I’m a big supporter for all of these metrics as inputs, but not direct drivers of resource allocation decisions or incentive pay. Ultimately, in seeking a pareto optimum, I subscribe to Deming’s admonition (his seventh “deadly disease”) that not all measures are known or even knowable. As a consequence a degree of subjectivity remains and it’s the leader’s responsibility to exert that subjectivity “fairly.”

Yet, as we at Maimonides Medical Center undertake to develop a fair allocation method, I’ll offer this essay and references to my colleagues on our Faculty Practice Finance Committee and seek their solutions and their engagement of their colleagues in crafting a solution. When we get there I’ll let you know how it turns out.

[1] Khan NS, Simon HK. Development and implementation of a relative value scale for teaching in emergency medicine: the teaching relative value unit. Acad Emerg Med, 10(8):904-7, 2003.

Incentive Compensation and training residents. How shall we manage the intersection? (Part 1)

Next month our third class of EM residents will start and we’ll have attained a full complement of emergency medicine residents, taking another step in our transformation from a purely service focused organization to a department delivering service and education while undertaking scholarly activities.

As I write this column the transformation comes to mind since we’ve just distributed our semi-annual profit-sharing and incentive payments, based as in the past on measurable clinical, academic, administrative productivity and my subjective evaluation of the individual physician’s contributions to the department. One quarter of the profit-sharing “pot” attributable to each factor. (I’m describing only our profit-sharing plan and not our base compensation plan which is that of hospital employed physicians.)

The residency program has imposed its own demands on practice earnings, though we’re not a medical school and thus pay no “dean’s tax.” I had agreed long ago when contracting with the hospital, that the faculty practice would support certain aspects of the residency in lieu of a dean’s tax. That agreement and the steadily increasing pressure on revenues all of us in medical practice have experienced over the years have appropriately raised staff concerns about profit-sharing income.

This month and next I’m going to describe our department’s efforts at improving financial performance while broadening the group members’ understanding of practice finances and fulfilling our educational mission. This month I’ll focus mostly on our billing improvement and educational efforts. Next month I’ll share some early thoughts about transforming our incentive program in keeping with the transformation of our department.

Recently, several outspoken physicians have worked on improving our charting quality as a first step to improving our revenues. We long ago had implemented straight-forward, housekeeping improvements: assuring charts were completed and signed, making sure we didn’t lose charts for billing, confirming that updates of insurance information to the hospital were shared with the practice. These and other best practices have been taught by many and I won’t review them here.

What’s new is our giving of near real time feedback to our physicians regarding the completeness of their charts. Though the value of regular feedback is obvious to all, making it happen can be a challenge with emergency physicians working shifts—coming and going each on his/her own schedule. In the era of paper charts and given realistic concerns regarding billing practices it had been impossible for us to accomplish. However, more recently our electronic medical record and the hospital’s virtual private network have permitted our staff to logon from home to complete their charts. One of our physician staff built a web based application that our coders use to send email to each physician about their incomplete charts and that tracks the physician’s completion of these incomplete charts as appropriate. Not all charts are appropriate for completion.

In consultation with hospital compliance and legal staff and discussion with several professional EM chart coding companies, we decided that only charts missing entire sections: history of present illness, past medical/surgical history, social history, family history, review of systems or physical examination would be referred for completion. Charts that addressed each area but appeared to our coders as lacking usual documentation would be referred for “educational review” but no expectation of chart completion would attach to the referral and coding and billing would be based on the original chart. We set a 72 hour limit on the physician’s response to the request. After 72 hours, even woefully incomplete charts are coded as-is.

Through this feedback and education process, coupled with attention to our coders’ training we’ve seen a reduction in incomplete charts and a general improvement (measured as RVUs/patient) in charting quality. It’s no surprise that some physicians have shown greater improvement than others. We anticipate revenue improvements as these early charting improvements translate into higher charges.

I’m sure you’re equally enthusiastic for improving collections, but not everyone has an electronic medical record and a hospital supported virtual private network. Yet, everyone does have colleagues who are not as preoccupied as you are. Engaging them in solving your revenue problem makes all the difference. It’s not merely a matter of demanding the behavior change; rather you want others invested in making the behavior change across all group members and make the change stick.

Supporting those junior colleagues requires both structure and constant mentoring from you. For a structure, I’ve created a faculty practice finance committee that will I expect develop further improvement ideas. For mentoring, I’ve offered my time and unfettered access to the semi-annual accounting of the practice plan’s revenues and expenses—though individual physician’s compensation will be available only in aggregate. I’ve also just ordered them each a copy of a book I first mentioned in my May 2000 column: Fisher and Sharp: Getting It Done: How to Lead When You’re Not in Charge. HarperBusiness, 1999; ISBN: 0887309585

With these efforts I expect that our team will not only develop solutions, but will bring others in the group in so as to improve upon the solutions the committee itself develops. Next month I’ll discuss how our group, now engaged in both clinical service and residency teaching might go about developing a profit-sharing plan that suits all medical staff even though physicians’ activities differ.

Patient Satisfaction Surveys and the Emergency Department

We just received preliminary and sobering results of our annual fourth quarter patient satisfaction survey, but more about our results later. The process we and our hospital use differs from the usual commercial patient satisfaction survey so, but since its value to us in the ED is so great, I thought it might be worth sharing with you. I’ve also recently learned of another approach—driven by the emergency physician group practice itself—that may hold some interest for you. So let me review these approaches; while neither may work as a “drop-in” for your environment and both have real expense, perhaps you can learn something you can use.

Our hospital conducts structured over the telephone interviews on admitted and discharged patients, interviewing sufficient numbers of patients to garner completed interviews with 100 patients monthly. Patients are interviewed in their language of choice including English, Spanish, Yiddish, Russian and more recently Mandarin Chinese. Arabic may be next. During the months of October, November and December both Pediatric inpatients and ambulatory patients are surveyed. We also survey ER outpatients and the care-givers of pediatric ER outpatients using an instrument designed in parallel with the adult/pediatric inpatient tool. The inpatient tool attempts to determine both by direct questioning and by confirmatory questions whether the patient was first whether the patient was admitted through the ER and if so asks seven questions relevant to the ER experience, only one of which could be considered to ask about the emergency physician. The question is broadly focused asking about all physicians that may have been involved in the patient’s care. We do not tie the individual patient’s comments back to a specific provider.

Both we and hospital administration look at the survey results as giving us useful information about systems and processes, not individual providers. What we do get is wonderful information that allows us to compare the experience of adult and pediatric patients admitted and patients discharged from the ER as well as longitudinal results over time.

Results include an analysis of both positives and negatives. We aim for no more than 10% in the bottom “strongly disagree” box and 90% in the top two “agree” and “strongly agree” boxes. Survey items are all posed in the affirmative. Our results since 2001 (survey conducted monthly, results reported quarterly) conform to Boudreaux and O’Hea’s findings that patient satisfaction is most affected by the quality of interaction with the ED provider.[1] Waiting time, perceived or real and the discordance among perception and expectation were a secondary factor in this literature review and analysis of opportunities for further study.

I’ve learned of two variations on an emergency physician centered patient satisfaction “survey” both of which I would characterize more as “callback” efforts intent upon enriching the patient encounter and improving patient satisfaction themselves. In both instances the emergency physician practices themselves conduct the process.

Tom Scaletta, MD, Chair, Dept. of Emergency Medicine, Edward Hospital in Naperville, Illinois, the emergency physician who designed and implemented the process describes his approach thusly:[2] “The callback clerk attempted to reach a cohort of all discharged patients. She called about 3,000 a month and reached about one-third. What she said was carefully scripted. Patients getting worse were told to call their PCP [primary care provider] or come back to the ED immediately. No further medical advice was given by the callback clerk though, if requested, the call was transferred to a nurse. The cost (about $36K a year) was about $1 per patient attempted or $3 per patient reached. This was a fulltime position by an administrative assistant with great interpersonal skills. Her job was facilitated by a callback database (FileMaker Pro™) which uploaded the prior day’s census, automatically dialed, and served as a user-friendly way to store the data.”
“The callback information was used to improve satisfaction—the act of checking on patient’s well being was positively received. We uncovered problems quickly and made recommendations to correct or documented improvement and assured adequate follow-up. All this helps minimize risk. Finally, we collected data on opportunities for the physician, nurse, and system to improve. We used a letter grade since patients immediately understood what we were getting at and a portion of the doctors’ bonus was tied to this grade. Overall, the docs received an ‘A’ 70% and a ‘B’ 25% of the time. The ratio of A:B was more influential than A/B:C/D/F in comparing the docs. The docs received monthly feedback and many were able to change their means of interacting with patients and improved their scores significantly.”
The other physician driven approach takes advantage of integrated information systems and telecommunications technologies to use automated dialing to leave a message in the physician’s voice to the patient. The message advises the patient to call 911, return to the ED or see their primary care provider if not improved or worse. It then goes on to solicit feedback with any concerns or comments regarding the patient’s care or experience in the ED. A patient request for a callback from the physician receives that response.
Our patient satisfaction survey results served as a sharp rejoinder to any complacency, reminding me that while excuses abound: space, staffing resources, upstairs-downstairs communication and conflicts; I must periodically remind myself and re-energize all staff in our commitment to care of our patients within the resources available. Patients and their families take for granted that they are getting good clinical care; caring for the patient must go beyond the clinical realm alone.

[1] Boudreaux ED and O’Hea EL: Patient Satisfaction In The Emergency Department: A Review Of The Literature And Implications For Practice, J Emerg Med 2004; 26(1) 13-26

[2] viewed on 2004 March 16

Implementing Emergency Ultrasound at the Bedside

The only constant in life is change. Change in ourselves and our practices is a reality and it’s ostensibly why those who regulate us prescribe minimum continuing medical education, periodic specialty recertification and other requirements. We ourselves mostly strive for more than those minimums for our own self-satisfaction and our patients’ well-being. Yet, try as we might, maintaining the clinical edge can be wearing.

My inspiration for this column comes from every clinician’s struggle for clinical currency, particularly as I observe colleagues over the past year or more adding emergency bedside ultrasonography to their practice armamentarium. At weekly case discussions, opportunities for bedside ultrasound are scrutinized for the effect on the patient’s outcome. Unspoken, but obviously considered by some of my junior colleagues is why wasn’t a particular patient studied with bedside emergency ultrasound in a particular instance? Did it have anything to do with the experience and training of the emergency physician?

Introducing emergency ultrasound (EUS) at my hospital has been more than a year-long project, fraught with difficulty and expense. I’m glad we proceeded and today have staff utilizing EUS regularly. Obviously, we needed to have a trained faculty if we were to teach our residents the skill, now required for an approved EM residency. Though we have a process for privileging our staff for EUS, the rate of acquisition of those privileges remains painstakingly slow. Am I supporting our physicians appropriately? How should I speed up the rate of acquisition of EUS skills among our nearly 30 physician staff?

First, since I know from conversations with colleagues that EUS isn’t universally deployed and so some of you may be interested in how we proceeded. Your hospital may require some variation, but in general, if you’re adding a new procedure to your list of privileges—and EUS was clearly a new procedure for us—the JCAHO requires that your medical staff process oversees the addition of EUS to your privileging list.

Since it’s likely that most of your staff, even if residency trained, completed training prior to the routine deployment of EUS, you’ll have to address the training and experience deficiency as part of the implementation. Therein lies much of the difficulty and expense—depending on the size of your staff, even more expense than the capital acquisition of and ultrasound machine itself.

We were fortunate because one of our staff had some relevant ultrasound experience from her obstetrical training, undertaken for several years before entering and completing an emergency medicine residency. She, as assistant residency director had been with us for several years and was a well respected by colleague, even by more senior staff. It would have been difficult if our only potential leader for our EUS program came from the ranks of newest graduates on our staff.

My somewhat experienced colleague had urged the purchase of an ultrasound machine for some time, so we went ahead and purchased one after a seeing several machines from different vendors. We tried several out for a week or so each in the ED before making the decision to buy. We had few users, but the availability of the device meant that some consultants could also use the machine and surgeons, cardiologists and obstetricians all did make use of it.

My colleague, though she was eager to proceed, felt that she needed to complete more formal training, both because of the limited focus of her previous experience and the period that had elapsed since her obstetrical experience. So we supported her for a month upstate where at another ED with an established EUS program she completed a self-study, didactic and practical program that gave her the skills and experience recommended by ACEP for an emergency physician performing EUS. Of course we paid her salary during this time and we paid her tuition, travel and living expenses at the other facility as well.

There she learned the techniques for the five core indications:
1. fluid, i.e., blood, in the abdominal cavity secondary to trauma or other causes including ruptured ectopic pregnancy;
2. echocardiography for cardiac activity and pericardial effusion/tamponade;
3. abdominal aortic aneurysm;
4. biliary ultrasound for cholelithiasis and cholecystitis;
5. renal ultrasound for obstruction.

She performed each of these studies in scores of patients so that she could gain experience both with normal and abnormal studies. All of her studies were reviewed by an experienced emergency physician and ultrasonographer—some in real-time, but many through static images and chart alone.

After returning home we then took our draft credentialing process to the chairman of radiology—merely as a courtesy—and to the chairman of the medical staff credentials committee. I also met with several of the medical staff officers and with several surgeons who were performing intra-operative ultrasound of the liver during intra-abdominal cancer surgeries. I brought not only our documents, but the documents from ACEP and SAEM on EUS and adopted AMA resolutions relevant to overlap of credentials among specialties and the entitlement of departments to credential their own staff.

I won’t tell you that all was smooth sailing thereafter. It was not. I was disappointed when the chairman of radiology rather than confronting me directly, instead wrote to the chair of the credentials committee. The same radiologist later relented and stood aside. He recognized that his department wasn’t providing the service around the clock and that our residency was dependent upon our developing facility with these focused studies which aid in answering specific clinical questions.

We ultimately gained executive committee support and implemented the ACEP guidelines as our process. A weekend of formal training for half the staff and the ardent support and engagement of a number of junior faculty who were trained in their residency means that we are doing more examinations all of the time. Yet, still some lag in acquiring the skill. How shall I address it?

Though our staff expect testing on ultrasound in the ABEM recertification program going forward, the pace of adoption remains slower than I like. I’ve continued my persuasion, arguing the value to patients of early decisions, consultation and disposition of bedside EUS. How have you brought this skill to the entirety of your staff or are you struggling also? Offering the training alone hasn’t been sufficient; what am I missing? Please write and share your thoughts.

Ambulance Diversion, Crowding and Patient Flow: The Headbone’s Connected to the Footbone—and Everything In-between

Sometimes we hear it said that things “come in threes.” I guess those believers were talking about my 309 patient day (in an ED built for 140 patients/day), the EMS Insider cover story reporting that Memphis had adopted a “No-Ambulance-Diversion” Policy[1] and the JCAHO’s promulgation of a new patient flow standard, LD.3.4., which includes, for example, among the nine elements of performance two elements covering space and facilities for both admitted patients held in temporary areas such as the ED and for ED patients themselves.

Memphis’ experience in doing away with diversion excited me. During the decade plus that I served as Philadelphia’s EMS Medical Director, I used to hear plenty of complaints from colleagues about patients brought to an already busy ED that had been “closed” to ambulance patients. I always responded that any ED, regardless of how stressed, had more resources than did two paramedics on the ambulance. It wasn’t a popular response. I’m not sure how my colleagues at Maimonides would feel about not using diversion. Seeing 80,000 patients annually in 17,000 square feet is a strain; seeing 309 patients in a day in the same space is a patient-safety nightmare.

Perhaps the space constraints of my Brooklyn emergency department limit the opportunity for a Memphis style experiment, though I am not one who would invoke the clichéd, “New York is different.” Los Angeles is struggling too: In the January 2004 Annals of Emergency Medicine Eckstein, Chan and colleagues report on “The Effect of Emergency Department Crowding on Paramedic Ambulance Availability.” This symptom of system overload and pending failure has now been scientifically measured and its impact quantified in one large city. Yet this report demonstrates to me yet again that departmental leadership of system improvements alone may be an inadequate response. Why? Because “form follows finance.”

Last month in this space, my colleague Dan Murphy commented, “Form follows finance,” in talking about palliative care and the need to focus on the whole person, not merely an ill organ system. He’s right about that, but implicit in his comment I also see the resource mismatch we confront (almost) every shift. Though few of us seem prepared for planned rationing, the phenomenon is already here in our overcrowded emergency departments and our requests for ambulance diversion.

Overcrowding and its consequences for patient safety are on my mind as I contemplate the 2004 JCAHO patient safety goals—effectively mandates. Patient identification by two means not to include the patient’s location is one of these “goals.” Not relevant to me in the ED you may think; my patient declares his or her need for intervention right in front of me, identification isn’t an issue. But has the wrong patient ever received the wrong x-ray in your ED? Such occurrences are more common than we’d like to acknowledge. Too often the complex cascade creating such error includes the all too “human error” of inadequate identification not because the transport aide and x-ray technologist just don’t care, but because they are harried by too many competing demands—perhaps fed by overcrowding.

As the expression goes, “The headbone’s connected to the footbone” and everything in-between. We’ve all come to realize that the functioning of the whole hospital connects to overcrowding in the ED. Improving patient flow and moving admitted patients out of the ED more quickly can reduce strain on the ED staff.

Just recently we had Carolyn Santora, RN and Peter Viccellio, MD of SUNY Stony Brook; speak to a wide cross-section of our hospital staff—including nursing leadership about their approach to managing over-crowding and patient flow. At Stony Brook they admit patients to the hallways. Of interest to me was their finding that over 40% of their patients admitted to hallways are moved into a room either on arrival (~20%) or within an hour of arrival to the floor (~20+%). The nursing units where these patients are admitted are nominally staffed at a ratio of one nurse to six patients. Contact Peter or Carolyn through Peter’s assistant ( for further information about the Stony Brook experience. For a variety of operational and cultural reasons, this is an unlikely step at Maimonides, though our nearest competitor hospital has implemented just such a process.

At Maimonides we are implementing tracking and communication software throughout the hospital that will make bed status explicit to everyone while facilitating communication with patient transport staff through pagers and telephone based interactive voice-response. This tool purportedly achieves substantial improvements in the speed of bed turnovers. Presumably, consequent to the publication of bed resources and their statuses along with improved communication and enhanced accountability of all staff responsible for bed turnover all steps in bed turnover take less time and beds become available more quickly. I’m optimistic for improvement in patient flow, but mindful that these measures are more “tinkering” when one looks at the totality of the hospital environment and how “form follows finance.”

Nonetheless, within my scope as director of a single emergency department this is what I can do. As a younger man through political activity and what’s come to be called, “direct action” I endeavored along with others to change our world. A bit older and somewhat battered—hopefully not cynical—I’m making efforts at the level where I can have some effect and sharing some of these efforts with you through this column.

I’ve regularly mentioned the emergency medicine mailing list, “emed-l.” (Join using the ED Subscriber) in this column. Setting your preferences to “digest” will result in only one message a day in your e-mail inbox, yet you can still read or quickly skip through the comments. As at least one presidential candidate has shown this season, the internet can provide a powerful organizing for a leader with a vision. Perhaps somewhere in the mix of clinical, financial, operational and political issues discussed on emed-l there may be some opportunity to address the “form follows function” observation and engender a formal public policy debate on healthcare rationing rather than limit ourselves to tinkering with ambulance diversion, ED crowding and patient flow.

[1]“Memphis Adopts No-Ambulance-Diversion Policy,” EMS Insider 30(12):1-3; December 2003.