Increased Efficiencies in VMC’s Emergency Department

To say that Dr. Jeffrey Arnold, VMC’s chief of the Emergency Department (ED) is a busy man is a dramatic understatement. He is in charge of heading up the team of docs and nurses responsible for providing emergency medical services in the busiest hospital in Santa Clara County, home to San Jose, the 10th largest city in the United States. We had a chance to sit down with Dr. Arnold and talk about some of the advancements in patient care and increased efficiencies that have been implemented over the past three years. We’re so glad we did, because the accomplishments the ED has seen since 2006 are truly remarkable.

When Dr. Arnold joined the ED in 2006, VMC was just starting to feel the impact of a surge in patient demand from the closure of the San Jose Medical Center, among other factors. They knew that if more and more people kept coming to the ED and did not act, they would run over capacity. Understanding the urgency of the situation, Dr. Arnold and his team of talented physicians and nurses went to work implementing changes to the way things were run in the ED. Just to give you an idea of the type of changes we’re talking about here, since taking over in 2006, the collective ED team has reduced the time to provider rate (the amount of time you wait to be seen by a doctor) by 9,000 hours each month. If you multiply that out over the entire year, just for fun, the residents of Santa Clara County were saved 4,500 days of human wait time in 2009. 4,500 days! Oh, and did we mention they save lives during all of that, too? Because they do.

2006: a new beginning

To get a true sense of how far patient care has advanced over the past three years, we should take a step back to 2006. In 2006, the average number of patients visiting the ED each day was around 200, or 73,000 a year. At that point in time, new systems weren’t yet in place to help accommodate such a large patient population, and wait times often suffered as a result. “Back in 2006,” Dr. Arnold explained, “what the patient experienced in our ED was going directly against why they came to see us in the first place. From a patient perspective, they came to see a doctor. They didn’t come to see anybody else. From a treatment perspective [the way we were running things] was preventing the patient from being united with what they came to get.” So Dr. Arnold and his team went to work immediately implementing two key processes to begin the process of repairing the patient experience: the expansion of the Express Care Clinic, and the adoption of Rapid Medical Evaluation (RME).

Express Care Clinic

Most patients who present at the ED throughout the day do not have immediately life threatening conditions. Those that do are, of course, rushed into the ED and treated immediately. But what happens to those people who aren’t having a heart attack? Before, they would wait for hours to be seen, or go elsewhere. But now they have a third, and much more reasonable, option: the Express Care Clinic at VMC.

“The Express Care Clinic serves patients coming to the hospital with urgent problems by combining an urgent care setting with doctors and nurses who are experienced in Emergency Medicine,” Dr. Arnold explains. This is a 14 bed unit directly adjacent to the ED. Each bed is in a private room that is stocked with medical equipment, and by the time each patient gets to a room, they have already seen a doctor. That’s right; the first person a patient talks to when they present at Express Care is a doctor. The intake doctor takes the patient through a filtering process called a Medical Screening Examination. They take a “why wait?” attitude with the goal of “keeping vertical patients vertical.”

“Once you take somebody, put them on a bed and put oxygen on them, they start looking a lot sicker than they actually are,” says Dr. Arnold. “If someone comes in complaining of pain when they urinate, it’s kind of a no-brainer; they need a urine test. Why would we make them wait another hour to get a room, to see a doctor, who then orders a urine test, etc. Why not just see them then? Send them to get the test, and by the time they get back the test results are there and a room is ready.” Today, nearly 70% of patients coming through the ED doors know to head directly to the Express Care clinic, a huge win for both the patients and VMC.

Rapid Medical Evaluation (RME)

This type of common sense approach to emergency medicine has gone a long way in improving the patient experience. A similar approach to care has been adopted by Dr. Arnold’s team in the ED proper. RME take is a small 4 bed unit right next to the ED proper which takes low acuity patients out of the pool that goes into the ED. RME is used for outer extremity injuries that are easily observed without need for additional observations like x-rays or CAT-scans. The same “why wait” approach is still applied to slightly more serious cases, preventing the unnecessary clogging of ED beds. Patients are treated in this small unit, and released directly from there.

Essentially, the team of doctors and nurses have created three levels of injury treatment to slot patients in to when they come to VMC: the ED proper, where people with life threatening emergencies should go. RME, where patients that present with non-life threatening but still emergency situations like lacerations can be treated. And Express Care, for less acute patients like those with chronic low back pain.

Results

If these changes were implemented during a period of time when patient use of the ED was staying steady, they would be impressive and still needed; but the results Dr. Arnold’s team have seen have been remarkable. In 2006, VMC’s ED department treated 73,000. In 2008 they treated 102,220 patients. In 2009, they hit 127,750. In the first month of 2010, the ED treated 12,144 patients. If they patients keep coming at that rate, VMC’s ED will treat 145,728 patients in 2010. That means that the patient rate will have doubled in 4 years. While the patient population has doubled, our VMC ED has reduced the left without being seen rate from 40% in 2006, to 2.5% in 2009.

“Statistics show that 1 out of 10 patients who leave an ED without being seen need to hospitalized later with greater morbidity and cost,” Dr. Arnold points out, “the difference we make is that four people every day are now getting care that wouldn’t have. That means that there are around 1,500 people out there who you have really done an incredible service to by preventing them from leaving without being seen.” To add to the degree of awe, these improvements have taken place with 50% fewer beds than what a patient population of that size is expected to have. They have streamlined processes, dramatically reduced patient wait times, improved the quality of patient care, and saved countless lives all within the context of a doubling in the patient population, having a deficit of patient beds, and budget cuts.

When asked what he was most proud of about his and his team’s work in the ED, Dr. Arnold summed things up with humility:

“We always have stories in the ED about how we heroically do something, or we make the right diagnosis, or save someone’s life by intervening at the right moment, and they are real stories. But the thing we are the most proud of over the past three years is affecting so many people in a positive population way. We have really good patients at Valley. They are really grateful, good patients.”