From coast to coast, hospitals are managing itriage between a rock and a hard place: emergency rooms stretched to capacity and a federal requirement to treat anyone who arrives with an emergency condition.

Crisis situations are spawning creativity, however, as administrators prove the power of tailored remedies to fix what may be a universal problem. New solutions rolled out in 2004 at two urban hospitals show how the best fix can vary with the role a hospital plays in its local community.

In central Phoenix, St. Joseph’s Hospital and Medical Center serves as the metropolitan area’s safety net facility in accordance with its designation as a level-one trauma center. But with emergency department visits increasing by 3% to 10% each year, the hospital needed a new triage policy to guide decisions about which patients to place in the unit’s 31 beds.

When brainstorming possibilities, St. Joseph’s took into account how its mission and revenue stream would both benefit from steps to maximize the number of patients treated on site, according to Kim Flanders, emergency department clinical manager. Early in 2004, the hospital adopted what it calls a fast-track system for patients whose ailments require no more than one test, such as an x-ray, to diagnose.

Under the new system, about 15% of emergency department patients (about 8,700 of the 58,000 seen per year) never occupy a bed. Instead, they answer a questionnaire in a waiting area, talk with a registered nurse, and then see either a physician or physician’s assistant in an adjacent room outfitted for five-minute encounters with fast-track patients. Commonly treated on the spot, most are on their way within the hour.

Typically, people are happy because they’re being seen, as opposed to waiting or being referred elsewhere, Flanders said. “We’ve really gone out of our way to make it convenient.”

Open late
St. Francis Hospital in downtown Milwaukee has faced similar spikes in emergency department visits, but there, a very different approach has since October 2004 been providing some relief to thinly stretched staff. Rather than aim to maximize the number of patients seen in the emergency department, St. Francis has joined two other hospitals in its network to refer non-emergency patients to specialized, federally funded clinics with extended hours.

For patients with a rash or sexually transmitted disease, for instance, this means the emergency department provides a phone number and address for the nearest clinic with necessary expertise. A case worker follows up to make sure the patient receives care as intended. And although patients with pain sometimes get angry when they must leave untreated, administrators feel confident the policy serves the best interests of patients and hospital alike.

“This is not just one hospital’s problem or one healthcare system’s problem,” said Debra Standridge, president of St. Francis Hospital. “It needs to be a priority on all of our lists to try to make the community much more healthy, to be able to provide access at the right time in the right place by the right people.”

The recent boom in emergency department visits seems to stem from a mix of factors. In part, Flanders suggested, Americans are accustomed to service without a wait, and emergency departments require no advance appointments. Another factor seems to be insurance, or lack of it. Patients without coverage are putting off routine treatments until their symptoms become acute, Standridge said, and then go to emergency departments where they know care will be available.

“If you know an MRI is what you need to get back to work, and you won’t get paid until you’re working again, will you want to wait six weeks [for an appointment with a specialist] or go to the ED?” Flanders said.

To address the crunch sufficiently, however, a remedy must fit the environment. Milwaukee’s approach, for instance, would work only where an established group of walk-in clinics is available to accommodate an influx of new patients. Even then, Standridge said, the system depends on proactive support from various institutions that share a common vision for community healthcare, in this case ranging from the Wisconsin Hospital Association to the Milwaukee mayor’s office.

Looking at revenue
At St. Francis Hospital, the outside referral of about 80 non-emergency visits per month means forgoing revenue from those 80 would-be patients. But because emergency care is costly to provide, the hospital may actually end up saving money through its referral system.

“The ‘revenue’ you’re seeing from this referable population is uninsured,” Standridge said. “There is no revenue.”

In Phoenix, however, St. Joseph’s sees every emergency department visitor not only as its responsibility, but also as a potential source of income. The hospital intends to open a new tower with an expanded emergency department in 2006. There, 40 beds will await the worst emergencies, with another eight designated for less severe cases. Fast tracking of those with sore throats and the like will continue as well.

Since adopting the fast-track approach in early 2004, St. Joseph’s has cut emergency department wait time in half, from about 100 minutes on average to about 50. In another sign of progress, Flanders noted that 15% of emergency department visitors used to leave without being seen, but now fewer than 5% fall into that category. And because the emergency department was already staffed, fast tracking has entailed some shifting of personnel but a minimum of capital investment.

“We were already paying the nurse to be out there,” Flanders said. “What’s more, in designating a registered nurse instead of clerical staff to manage the patient intake process, it has really reduced our risk.”

G. Jeffrey MacDonald is a correspondent for the Christian Science Monitor. Based in Newburyport, Mass., he can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it