At midafternoon on a recent weekday, the vast waiting area at University of Colorado Hospital’s new emergency room is empty. Missing are the dozens of patients who crowd a typical ER lobby, often waiting more than an hour to see a doctor. Empty, though, does not mean idle.
Behind secured doors, a warren of treatment rooms is packed with complaints of chest pain, dizziness and earaches, some of the 230 patients University Hospital’s ER will see on a given day.
That’s just the way the design team wants it. They meticulously planned the space to employ retail magic alongside medical miracles, putting the hospital at the forefront of a national movement to deliver health care with industrial efficiency.
Members of the ER staff chat on earpiece radios, measure “door to doctor” time from a keystroke at a portable intake stand, and carry titles such as “pivot nurse” and “scribe.”
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The goal was to reduce ER wait times — which the hospital calls “door to doctor” — from nearly 80 minutes to 10 to 15. Results so far have been dramatic: The average since opening the department early in April is 10 minutes.
Before the expansion, the hospital lost hundreds of patients a month who fled frustrating wait times without being seen. Last month, they lost none.
“Fast is good, when you’re sitting in pain,” said patient Mary Freeze, jaw set grimly in agony from post-gall bladder scar tissue. Freeze was one of a dozen patients whisked to an exam room after pausing only for a tracking wristband.
The new ER, which University Hospital opened the first week of April, is double the size of the one it built just six years ago when it moved to Anschutz Medical Campus. With University Hospital’s rapid growth throwing off piles of income to reinvest, the facility has reshaped the consumer experience — though not, as critics note, to lower the sticker price.
The new space is a culmination of years of rethinking everything in the ER, using manufacturing and ergonomic tools to pull apart decades of health care tradition.
“What we have done may be novel in medicine, but it’s standard industry practice everywhere else,” said University Hospital emergency medicine chief Dr. Richard Zane. Zane’s chief designer of the new ER process, Derek Birznieks, came from a career with Caterpillar heavy equipment.
Hospitals across metro Denver and the nation are undertaking similar revamps of ERs, which serve as the public “front porch” of billion-dollar institutions. Their aim is to cut hours-long waits and cement a positive image for consumers who may return for other services as hospitals become conglomerates.
Other touches in University Hospital’s new ER, either high-tech or humanizing, include:
• Nurses and technicians wear earpieces and microphones, like those used at clothing retailers and fast-food counters, to chatter about open rooms and patient priorities.
• Wheelchairs are stacked like grocery carts at the ER entrance. Patients are pointed to them immediately whether they need them or not, partly to control flow, partly to convince them their care has begun.
• Computer monitors listing patients and conditions, like the scrolling drive-through orders at Starbucks, pop up a red “Stop” sign at a patient’s two-hour mark. Time for the ER staff to make a decision about care, and get moving.
• Employees in a new category dubbed “scribes” follow on the elbows of ER doctors, rolling a laptop on a stand. The scribe starts typing as soon as the doctor enters an exam room, taking patient history, calling up pharmacy records and ordering lab work for results within minutes.
• Ambulances no longer pull in, turn and back up to the ER bay; those so-called K-turns take time and cause safety hazards. University Hospital, as Exempla St. Joseph is also now doing, built a covered and heated bay in a semicircle.
Within seconds of arrival from a bus, Monique Duran and three of her children were through the metal detector and being examined by technician Mason Horton.
The speed was a sharp contrast to Duran’s normal day. She had endured two buses and light rail from the Englewood shelter where her family lives. Duran needed treatment for a sprained ankle, and her 10-month-old twins had ear infections.
Duran’s family was quickly placed in the “supertrack” area behind the intake rooms, an intermediate step before the intense, trauma-ready rooms of the primary ER near the ambulance bay. She was given Vicodin for the ankle pain, and her 7-year-old son, Joseph, got a bag lunch from the cafeteria.
Duran then sat in waiting mode, no medical personnel in sight, as they looked for an air cast for her foot. But she was grateful, unable to return to the shelter until 5 p.m. anyway.
“It’s still much faster than anywhere else,” she said. She and the kids had been assessed, and treatment was on the way.
New hospital space is designed with the customer experience in mind, but only up to a very clear line, health policy experts note. Price is never a factor, as it would be for the Walmarts and United Airlines, whose processes the medical designers say they are copying.
“You and I aren’t paying the bill, so we don’t care how much it costs when we’re in the doctor’s office or hospital,” said Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins’ Bloomberg School of Public Health.
Most ER patients’ visits will be covered by private insurance, Medicare or Medicaid, or by a state indigent-care program. ERs are loss-leaders for hospitals, Anderson said; emergency medicine won’t make a profit, but more efficient service can reduce losses.
“Nonprofit” hospitals such as University make much money elsewhere — on inpatient stays or innovative day procedures — although they can’t distribute profits to shareholders. They spend their “profit” on construction and acquisition instead.
In fiscal 2012, University Hospital reported operating income of $147 million, on revenue of $941 million.
The new emergency department is part of a $400 million, 12-story addition to University Hospital’s Anschutz location that will add up to 276 beds to the existing 407.
“Over time, patient experience and quality metrics will affect the bottom line” as ER consumers decide to return to a system they like, Anderson said. “So if you have money, that is a good place to invest.”
Exempla is employing similar techniques for its ER as part of a $630 million rebuild of its central St. Joseph Hospital. Denver Health overhauled its ER and urgent-care areas a few years ago, as part of a long-term industrial-design process called “Lean,” pushed by former CEO Patricia Gabow.
St. Joseph will expand its senior ER, with no-slip flooring and subdued lights and alarms. Rather than employ the scribe system, doctors will take history and make orders with dictation tools based on upgraded voice-recognition software.
Denver Health continually upgrades with staff-suggested redesigns, such as “spaghetti” diagrams. The impromptu maps show all the hallway trips one employee takes to treat, say, an ear infection. If they can cut the paths through the ER from 14 to 11 in that one treatment, time and money win.
University Hospital brags that it measures everything in its ER, and tells staff what could be better. That could wreak havoc on bedside manner, but designers say shorter waiting time is always the first demand of ER patients.
Patients admitted to a full ER trauma or observation room are now discharged within 446 minutes, down from 855 minutes.
Chris Widener and a friend who drove him set aside an entire afternoon for Widener to seek treatment at University Hospital for mouth pain. Instead, they were whisked to an intake room, seen for a few minutes, then sent back out the front door to the in-house, 24-hour pharmacy window.
“That’s service, right there,” they said on their way out.
Staff at redesigned ERs must be flexible, rotating quickly from traffic cop to hand-holder to temperature-taker.
Registered nurse Deb Haefele stands near the University Hospital entrance like a maitre d’, listening to her ear chatter and holding a laminated room chart covered in X’s and O’s made by a marker. Her duties are altered, she said, but not the basic job description of emergency medicine.
Date: May 5, 2013