Hospitals shorten the waits in ERs

Diverting ambulances soon to come to end

Emergency room waits are decreasing at some Massachusetts hospitals as they prepare to comply with a new state rule that, as of New Year's Day, will prohibit swamped ERs from turning away ambulances.

Since state public health officials decided last summer to end the closing of ERs, a practice called "diversion," hospitals have aggressively taken steps to speed the flow of patients through their emergency departments, including hiring more nurses and doctors.

Crowded emergency rooms often are caused by backups on inpatient floors, so hospitals are finding ways to discharge patients more quickly. Tufts Medical Center is requiring phlebotomists to draw patients' blood earlier in the morning to hasten tests, and several hospitals plan to suspend teaching rounds and lectures when doctors are needed urgently to move patients out.

Even before the regulations go into effect, these and other changes are causing significant drops in the number of hours ERs are temporarily closed to ambulances. Statewide, hospitals were on diversion 7,963 hours through November of this year, compared with 11,605 hours for the same period in 2007. And last month, ERs were closed for just 232 hours, less than one-quarter as often as at the beginning of the year.

Doctors and others predict the new system will be better for patients, who currently can be sent to hospitals that don't have their medical records and where their regular doctor doesn't work.

"Patients want to go where they have a history," said Richard Serino, head of Boston Emergency Medical Services. "Family members will take out their frustration on the crews."

There have even been stories of disgruntled patients getting out of ambulances near their preferred hospital and walking into the ER. Hospitals are not allowed to turn away walk-ins when they are on diversion.

The danger of banning diversions, however, is that busy emergency rooms won't be able to handle the onslaught, especially if it's a bad flu season. "One of the big fears is that ERs will be overwhelmed and that there will be longer waits for less acute patients," said Elaine Bridge, senior vice president for patient services and chief nursing officer at Newton-Wellesley Hospital.

"ER staff are anxious about this change in policy," Bridge said.

Newton-Wellesley hired consultants to recommend ways to discharge hospital patients faster, leading to a 10-hour drop in the average length of stay to three days, 14 hours.

In a letter to hospital executives last summer, Paul Dreyer, director of healthcare safety and quality for the state public health department, said several national patient safety groups and the American College of Emergency Physicians discourage the routine use of diversion to solve ER overcrowding.

While the practice may give hospitals temporary breathing room, Dreyer has said in interviews, it has done nothing to solve the underlying problem in the healthcare system - patients being put in ER hallways because hospitals have no open beds.

Diversion, he has said, is a crutch that causes more problems than it solves, interfering with patient choice, increasing the time patients spend in ambulances, tying up the vehicles, and shifting crowding to other hospitals.

Generally, hospitals have been able to go on diversion for up to four hours at a time when the ER reaches "saturation" and there is room for patients at other nearby hospitals, though ambulances can override the diversion in extreme emergencies. Under the new policy, hospitals will be allowed to close their ERs to ambulances only if they have a serious internal emergency, called a "code black," such as a major fire.

That hospitals have reduced ER closures as much as they have without major problems shows that it can be done, Dreyer said. "The key is commitment from senior management," he said.

Massachusetts General Hospital, which has the busiest ER and some of the longest waits for an inpatient bed, has reduced the number of hours ER patients wait for a bed from 8.2 hours in July to 6.7 hours this month, despite an increase in the number of ER patients, said Dr. Alasdair Conn, chief of emergency services.

The length of stay for patients being discharged from the ER also dropped, from 4.2 hours to 3.8 hours.

Wait times were reduced, he said, in part by adding three doctors and 10 nurses and opening four triage rooms so that all patients receive an initial evaluation within 30 minutes.

At the same time, Mass. General is discharging patients from inpatient floors more quickly. The urology department is scheduling more elective surgery patients for Thursdays and Fridays, so patients recover in the hospital over the weekend, when more beds are free, and probably will expand its surgery schedule on Saturdays.

As a result of these steps and others, the hospital also has reduced the number of hours it is closed to ambulances, Conn said.

In most years since the state started keeping records in 2002, Massachusetts General has been on diversion more than 1,000 hours a year. Through November of this year, the hospital ER had been closed for 854 hours.

Brigham and Women's Hospital, which last year was closed to ambulances for 876 hours, six weeks ago opened a "surge pod' that can house 10 emergency patients who are waiting for hospital beds, which is freeing up more space in the ER.

The hospital also is finishing a "code help" plan that will include suspending teaching rounds when the ER is overflowing and doctors are urgently needed to discharge patients on the floors.

Boston Medical Center, which already closes its ER far less often than other Boston teaching hospitals, is developing a similar all-hands-on-deck policy when the ER is overwhelmed.

"There is going to be an alert that says stop whatever you are doing and do whatever you can to discharge patients," said Dr. Jonathan Olshaker, head of emergency medicine. "We are putting tremendous focus on this."

Liz Kowalczyk can be reached at kowalczyk@globe.com.

Correction: Because of a reporting error, a Page One story yesterday misidentified the hospital with Boston's busiest emergency department. Boston Medical Center has the busiest, with 126,039 patient visits in fiscal year 2007.