Archive for the ‘Dr Todd Warden’ Category

ImageIt has been a pet peeve of mine for a number of years of the terrible emergency care mostly due to my personal experience of a cancer patient and observing the long waits. This prompted me to sponsor a symposium on emergency care based on process design with the people who are the best with Terri Zborowski and team at  Ellerbe Becket AECOM and Dr Todd Warden, a leading ER specialist from the US who amazing with his expertise brings the wait time down to 9 min.

What was there not to be impressed? We had eight Ontario hospitals participate and some who could not attend attend due to timing conflicts received a package. The bittersweet irony was that Ontario Long Term Care called and stated great idea but because it is free we just “don’t know what to do”. Despite the setback I continued to contact physicians across Canada and sent the info package.

Well, something must have worked because my wait time in the Toronto General Hospital or better known as TGH was only 30 mins and I was sent directly to a room. The waiting room was even clean and I noted it was divided into two sections of triage those registered and those waiting to be registered.

I was pleased with the prompt care, diagnosis and treatment. The staff did not appear hurried although one nurse thought I was a renal transplant without checking my ID band and the ER physician, Dr Salmon who was professional was running out the door when I tried to ask a question. This is one reason why I like to pay directly for care at the Mayo because then there is more of a customer patient service. This caused some problems when the pharmacist had to call back the doctor to clarify a medication as it was contraindicated as an allergy on my alert. I hate clogging up the system.

I had to chuckle when I heard a nurse in the next room telling the patient  to order pan medication because she is paying for it anyway through OHIP- it is free. So don’t hold back.

I was impressed when I left the ER well under 8 hours with my prescription in hand to see a room off to one side with big words, “Rapid Assessment” and that helped eased the clogging with triage. I am sure this was part of our input from the symposium as our diagrams clearly indicate this process, although I never knew until I was again, the patient who is the real test.


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Everyone has been at the emergency department at one time or another. The experience more than likely would be described as horrifically long wait times sometimes 12 hours, crowded conditions, dirty, understaffed and a million other reasons.

Recently in Halifax and Dartmouth, Nova Scotia there has been reported problems at Dartmouth General and the QE II in a story by John McPhee at The Chronicle Herald with the emergency department overflowing.

Yet there are positive Emergency experiences.

I had the opportunity to meet Dr Todd Warden, ER specialist who has re-imagined what ER care should be-

Dr Todd Warden came to Toronto for Road Map for Change in April 2011 to share his knowledge.

As a conclusion of the symposium there is a call for a Canadian hospital to answer the call to welcome the opportunity to learn from Dr Warden pro bono for a special ER project. Interested parties to contact roadmapchange@gmail.com

Recently, Dr Warden’s work at Lehigh Valley Hospital has been documented in his work as described by Dr. David Burmeister, Department of Medicine as “re-imagined the way emergency Medicine is delivered”. The process has changed to include the “rapid assessment unit”. November 29, 2011|By Tim Darragh, Of The Morning Call reports it is a new way of looking at emergency care and instead of sitting in the waiting rooms, they are seen by a team of specialists.

ED Insights by Dr Todd Warden/Unintended Consequences;A Tale of Paradoxes and ED Crowding

The Triage Paradox
When I took my first job out of my residency in Emergency Medicine in 1982, I started in an active Emergency Department in South Philadelphia.  Like most EDs at the time the volume of this department would grow dramatically over the ensuing years making the ED insufficient in size and performance.  Since we were young and competitive we became obsessed with limiting the time that patients were in the waiting room as a sign of our proficiency in our craft.  Early on we noted that though there was great value in having patients triaged when the department was overwhelmed there were many times that patients were being systematically triaged even when we, the ED physicians, were ready to see the patients.  We had found ourselves actually going out to triage and the waiting room to bring patients back into the ED to bypass triage and reduce delays that traditional triage and registration were causing.

Throughout the 80s and 90s triage would become more established as a standard and the triage process would be expanded from 3 levels to 5 in an effort to better “fine-slice” the patients to assess their fitness to wait for intervention in the waiting room.  However, there were unintended consequences associated with the greater intensity of the triage process.  As triage became more technical and complex, more steps were added to assure all patients who required immediate care were identified.  Triage evolved into an area to not only screen patients with complaints such as chest pain, but it became a place where the work up was initiated by performing EKGs, drawing bloods and initiating protocols to facilitate the process and getting the testing started.  As the number of screening protocols in triage expanded they became part of the problem and contributed significantly to delays to the patients being seen by the provider.  By the late 90s and into the next decade most EDs had created triage systems that were creating delays rather than being a solution to sort patients and identify those that required immediate care.  As ED volumes increased there were greater queuing delays at triage and many hospitals found it necessary to have patients sign in on a log in order to keep patients and their chief complaints prioritized.  I remember working in a an academic center in 2003 – 04 and was perplexed by the lines that were forming in front of the triage nurse sometimes 6 or 7 patients deep.  Then when I scanned the waiting room I saw patients lying on benches or sitting in wheelchairs waiting for access to a bed in the ED.  Some of these patients were so ill they had been given emesis basins so they could vomit in the waiting room without soiling the floor.  The “triage paradox” had occurred.  The triage process complexity and the time it took to perform all of the screening and work up had become a part of the patient’s delay.  When we asked the patient’s to log their complaint we used that to select the next patient to evaluate.  We had in essence regressed to asking patients to triage them selves.

Initial Attempts to Improve ED Crowding
In the late 90s and early 2000 many leaders and experts in Emergency Medicine began to take note of the “triage paradox” and began to experiment with solutions to avoid the line at triage and the delays in patient throughput.  At that time I was transitioning from an executive position with the countries largest EM management company to found Emergenuity, a company with a primary focus of finding a process solution to the ED crowding crisis.  I also began to experiment with “immediate bedding” strategies in the form of bedside triage and registration.  At the time we all felt that if we could get the patients in front of the provider earlier, we would be able to eliminate much of the delay by by-passing the complexity of the triage process we had created.  Our hope was that if we could move the patient to the provider without a built in queue, perhaps triage would be less necessary.

Unfortunately this only provided several hours of relief.   As one would expect as we moved patients into existing beds soon became filled.  The patients pooled behind this next bottleneck in the flow process, that being the limitation on available beds.  It became clear that merely eliminating the initial bottleneck at triage and registration was not sufficient to promote patient flow through the department.

The Emergency Department Construction Boom
Soon after it became clear that immediate bedding strategies highlighted a bed capacity limitation, there was an immediate rush to increase ED capacity through ED expansion and new construction.  This boom to create “super-sized” EDs was fueled by several high-profile ED projects where cost; technology and square footage were virtually unlimited.  Unfortunately there were no “post-occupancy” assessments of these new ED’s performance.  If there had been the continued construction of these massive and oversized EDs may have been a bit more muted.  These new EDs came with their share of unintended consequences that dramatically limited their performance success.   The problems included over-reliance on the latest technologies; expansive space and division of care into specialized services that made it difficult to visualize what was actually going on in the ED.  In addition, there was lack of management expertise and methods to help ED leadership manage departments of this scale.  This often resulted in EDs that performed worse than the ones that they replaced.  This cost many ED Medical Director’s and Nursing Director’s to lose their jobs when the performance expectations did not match the magnitude of the capital and operating investments that had been made.

The ED Expansion Paradox
The super-sized EDs that became popular in the 2000s were flawed conceptually because they relied on the acceptance of a less efficient model of care.  The belief was, that since we cannot increase the efficiency of the ED through process and design enhancements, we must build our way out of the crowding problem.  This was a critical mistake in retrospect, and created an EM culture that relied on assumptions of bed capacity that have been decreasing over the last 10 years.  In the 1980s it was assumed that a typical ED bed would be able to accommodate about 2,000 patients per year.  However, as the Emergency Medical community became overwhelmed with their failing ED performance, in the face of many attempts to improve ED flow, they came to believe that previous assumptions were wrong and that the true capacity of an ED bed was far less, more like 1,500 or some would conclude that an ED bed could only see 1,200 patients per year.   This thinking has not led to a leaner, meaner fighting machine when it comes to ED process and patient throughput management.  It has had quite the opposite effect, and it has fueled the assumption that the only effective way to expand capacity is to build more beds.

When I started Emergenuity in 1999 my first client was one of the first and most effectively branded of the new ED prototypes.  This first of its kind new breed ED more than tripled the square footage over the tired old city ED that it replaced.  It featured separate specialized care areas, technology and greater privacy.  They added ample additional staff but the ED’s performance was far worse.  The “expansion paradox” no matter how much space, staff and technology was added, these EDs performed poorly.  In 2000 I was brought in to assist in the stabilization of this ED to analyze the causes of the failure, which had led to very significant financial overruns in operations.

Figure 1 – An example of one of the first of a new breed of EDs circa 2000.

It took years for me to begin to understand this “expansion paradox”.  This exploration has led me to a much better understanding of all the intricate moving parts of an ED and I have learned how small changes or large changes in process, design or both can have a dramatic impact on performance outcomes, good or bad.  This story has been repeated again and again over the last 10 years and yet we are still building larger and larger departments.

Both the “triage paradox” and the “expansion paradox” hold important lessons for us today.  The first highlights the fact that what may seem like an apparent obvious process enhancement and is implemented with all of the right intentions can have the total opposite effect than is anticipated on patient outcomes and experience.  The second demonstrates that additional investment in expansion of space can create unintended consequences that have the opposite effect than what one would naturally expect due to poor process and design integration.  It is prudent to understand their power and learn how to utilize them effectively.  In future issues of this newsletter, we will begin to develop proven ideas on cost-effective ways to increase ED capacity that focus on creating ED beds that have far greater capacity than has been believed possible in the past.  Rather than just building or adding beds we will discuss how to convert existing beds into “high capacity” beds.  Also when building a new ED is necessary we will discuss how to create a more compact and efficient model.  As the “expansion paradox” has showed us, we cannot build our way out of poor ED performance.  That is not to say that there are not EDs that need to expand, many will need to do so.  However, we will show you the road to smarter beds, smarter utilization of resources and technology that will keep costs of existing beds and expansion beds to a minimum while assuring success in the investment.

Copyright: No part of this can be used without permission of Dr Todd Warden

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