A young male patient checks into the emergency department (ED) and is brought back to a room for an ankle injury he suffered the day before. He states that he twisted it while doing some indoor rock climbing and tells the triage nurse that it is swollen and tender, but that he can walk on it. His vital signs are registered, and he is brought back to a room where he is told: “The doctor will be right in to see you.”
Almost simultaneously, another patient arrives into triage. He is a bit older than the first and is sweating and holding his chest. He has chest pain, and an electrocardiogram (EKG) is performed within minutes. It reveals an acute myocardial infarction, a heart attack. In medical terms, he is having an ST Elevation Myocardial Infarction (STEMI), which means a major coronary artery, the blood vessels that supply the heart with blood and oxygen, is completely blocked. He is rushed back to a room where the team jumps into action.
In the room two providers, a physician and nurse practitioner, start placing orders, while a team of nurses and emergency department technicians expertly attend to this patient. Arrangements are being made for transfer to a hospital with a cardiac catheterization lab, a procedure that allows doctors to find the blockage and open it up with a balloon and a stent. The patient receives medications, has labs drawn and an X-ray all within minutes. The ambulance arrives and whisks him away, having spent only 20 minutes in the ED. He undergoes the cardiac catheterization, the blockage is relieved, and he makes a significant recovery.
Meanwhile, the patient with the ankle injury is waiting. He keeps peeking out the door looking for when the doctor might make her way in. No one has asked him if he needed anything for pain. He sees doctors and nurses walk hurriedly by, but no one has stopped to ask him if he needed anything. “I was told the doctor would be right in,” he thinks to himself.
Two hours and 20 minutes later, the doctor arrives. She examines the ankle and tells him that the X-ray looked fine. She discusses what a sprain is, what to do for it and when he should expect to feel better. He is provided with an elastic wrap and an ankle brace and told to follow-up with his own doctor. In 10 minutes from start to finish, he is handed paperwork and is on his way.
A patient satisfaction survey is sent to one of these patients. This is a commonly employed method for hospitals to access data on patient satisfaction with services provided to their patient population. Examples include the Press Ganey survey and the Hospital Consumer Assessment of Healthcare Providers and Systems. Both surveys utilize data gathered from recently discharged patients to assess patient satisfaction with their care and experience. This information can be used to address the needs of patients better, identify areas that are excelling as well as areas that need improvement.
The key here for the emergency department, however, is that these surveys are sent to “recently discharged patients.” In the ED setting, that means patients who were seen and then discharged. These are most often the lowest-acuity patients. This population may have to wait the longest to be seen, and visits are often short. Low scores that result from this then become a focal point, and ED policy can be negatively impacted by focusing on the wrong population of patients. The critically ill who likely receive excellent and attentive care aren’t factored as a metric for evaluating ED performance.
When designing any survey, it is imperative that the design captures the appropriate audience. You have to make sure to poll the right people to get to the right answer. The cohort has to be representative of the entire ED population.
For example, if a given ED receives several surveys like the one for the ankle sprain patient, they may start to see access to care for lower-acuity patients as a priority. They may dedicate physical plant space to a fast track and hire several providers to staff it. This may seem wise, the scores among these patients will increase, and this is a metric that everyone can celebrate. The impact, however, is that there will be fewer bed spaces for the sickest patients. Provider resources, including nurses, techs and other providers, will be shifted towards lower acuity patients. This means fewer resources for emergent and critically ill patients. This is despite data that suggests that the low-acuity patients aren’t actually responsible for ED overcrowding. That stems from the more critical patients who draw more resources, or boarding patients who are waiting for an inpatient bed. Instead of opening up space for boarders, the fast-track attends to low acuity patients with little to no impact on crowding.
Policy, plant design and throughput of the emergency department should be driven by evaluating engineering, patient-safety and outcomes data. It should not be driven by a survey designed to evaluate metrics that don’t address any of these issues. The ED is not a drive-through restaurant and using data points that address points far removed from these more important metrics is somewhat irresponsible. It is imperative that hospitals and EDs poll “the right people.” This may involve not polling at all but instead dedicating resources to evaluate true measures of ED success and the delivery of safe and efficient emergency care.
Stephen P. Wood is a nurse practitioner and can be reached on Twitter @stephenpaulwoo4.
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