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Attending physician Niels Rathlev (in white coat, facing camera) attended to a patient last week along with other members of the Boston Medical Center emergency room staff.
Attending physician Niels Rathlev (in white coat, facing camera) attended to a patient last week along with other members of the Boston Medical Center emergency room staff. (Globe Staff Photo / Evan Richman)

Emergency room recovery

Busy Boston Medical Center eases delays by keeping 'customers' moving

It is one of the most desperate, chaotic places in Boston, an emergency room that receives three times more ambulances than any other in the city and treats patients who are likely to be uninsured, victims of violence, or unable to speak English.

But Boston Medical Center, the city's safety net hospital, is becoming a model of how to bring relief to the nation's beleaguered emergency rooms, reducing treatment delays and closures to ambulances when ERs are more crowded than ever. BMC emergency doctors are treating more patients than they did last year and have reduced average time in the waiting room from 60 minutes to 40 minutes.

The secret lies in a radical idea for medicine, but one that has guided airport managers and restaurant hostesses for years: Keep the customers moving.

Urged on by a Boston University consultant, the hospital is eliminating obstacles that force patients to needlessly remain in the ER. It is cleaning up empty hospital rooms faster and rescheduling elective surgeries so surgery patients don't take up beds that emergency patients need.

Meanwhile, ER nurses stationed in the waiting area assess a patient's condition within minutes of arrival and then use a color-coded chart to track how long patients have been waiting. The doctor in charge, Jonathan Olshaker, sometimes refers to patients as customers.

"I won't be surprised if five years from now, this is the biggest change in healthcare," said Dr. Donald Berwick, president of the Institute for Healthcare Improvement of Boston, an influential think tank that last week hosted a session on BMC's reforms for hospital officials from around the country. "We have to bring the science [of management] back into healthcare in a way that we haven't in a very long time."

At stake in the new emphasis on efficiency is not just patients' convenience, but also their safety. Victims of heart attacks and strokes can suffer irreversible harm if they aren't treated immediately. Even a seemingly stable patient, such as someone with abdominal cramps, needs prompt testing to be sure the pain isn't caused by a serious condition such as an aortic aneurysm.

Already, the private group that rates the nation's 6,000 hospitals is adding an efficiency standard in January based on the reforms at BMC, requiring hospitals to prove they are trying to treat emergency patients more quickly as part of their accreditation review.

"Anybody who comes to me and says, 'I can't do this,' I'm going to send them to Boston Medical Center," said Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO.

The hospital's changes since last fall have reduced the typical ER stay by 30 minutes, to 3 hours and 45 minutes. That's still half an hour above the US average, but impressive considering Boston Medical Center's heavy patient volume and difficult caseload.

Patients receiving treatment yesterday said the emergency staff is attentive and aggressive and has reasurred them that they won't be forgotten.

Alexis Morales, 36, said doctors went to work on him moments after he arrived with breathing problems from an asthma attack, giving him epinephrine and other medications to open constricted airways so that he wouldn't need a breathing tube. An hour after he arrived, still wearing his landscaping boots, Morales was breathing on his own in an ER bed, praising BMC's care.

"When I first started working here, not a lot of people said 'thank you,' " said Morales's nurse, Bree Sullivan, who has worked in the ER for 2 years.

Likewise, Caryn Hibbard, 32, said she was impressed by how quickly doctors ordered a CAT scan after she told them that doctors at another hospital had failed to find the cause of abdominal pain that had begun several days earlier.

"There were so many people coming and going all around me," said Hibbard from her ER bed as she drank the contrast medium needed for an abdominal scan.

The gains at Boston Medical Center, part of a two-year-old project called Urgent Matters, have been made amid signs of increased ER overcrowding. In Massachusetts, where one-third of ERs have closed since 1981 and hospitals routinely divert ambulances to other medical centers because they can't handle more patients. The state's hospitals set a record for ambulance diversions during the flu outbreak in December.

Other hospitals have tried to cope with crowding by expanding the ER, only to find it doesn't solve the problem. For example, South Shore Hospital in Weymouth just built the state's largest ER, but that hasn't stopped complaints from patients who say they were forced to wait hours with life-threatening conditions, including a woman whose appendix burst while she waited six hours for treatment of appendicitis.

"A few years ago, most people saw emergency room overcrowding as a matter of getting a bigger emergency room, but that was kind of silly," said Dr. John Chessare, chief medical officer at BMC who has spearheaded the efficiency push. "We realized we needed to manage our operation the way all other service industries manage."

At first blush, Boston Medical Center seems an unlikely place for a management revolution, if only because the state's busiest ER is so hard-pressed, handling about 300 patients a day.

Straddling the city's South End and Roxbury neighborhoods, the 547-bed hospital gets by far the most uninsured patients in the city, many coming to the ER because they don't have a family doctor. At the other extreme, as a trauma center, BMC gets a disproportionate number of people who have been shot or seriously injured in a motor vehicle accident.

Making the medical staff's job even harder, a third of BMC patients don't speak English as a first language, requiring a translation department with 36 employees.

But BMC's emergency room became a perfect testing ground for the theories of Eugene Litvak, a Russian-trained professor of health care and operations management at BU, who believes that emergency room delays are a symptom of poor hospital management.

In Litvak's view, the big problem for ERs is not the unpredictability of flu outbreaks and car accidents, but the lack of available beds in the main hospital where ER patients can go once they're admitted. If hospital administrators took greater control over the scheduling of nonemergency surgeries, from hernias to coronary bypasses, they could spread admissions more evenly, so they don't block emergency patients who need a bed right away.

Chessare, who was eager to improve his ER's performance, joined Litvak in getting a grant from the Robert Wood Johnson Foundation to test Litvak's theory, requiring him to do something hard in the hospital world: tell surgeons to change their work schedule. First, he approached Dr. Jim Menzoian, chief of vascular surgery, about spreading out complex surgeries through the week so that vascular surgeons didn't unwittingly delay ER patient admissions on Wednesdays and Thursdays, when they did most of their surgery.

"I have to admit I didn't like the idea in the beginning, because, you know, we're doctors and we don't like people to keep telling us what to do," Menzoian said.

"But we want to be team players," he said, so the surgeons changed their schedule last October.

Now, Menzoian admits, the program works with little inconvenience to the five surgeons in his section and with fewer complaints about delays from patients who come to him through the emergency room.

Chessare looked at other inefficiencies, such as the time it takes to get a room ready in the regular wards for the next patient. To his chagrin, Chessare discovered that it took 90 minutes, largely because of delays in notifying housekeeping that a room is empty. Today, Chessare boasts that the average bed turnover time is 63 minutes.

Emergency department chief Olshaker said the commitment of Chessare and other top officials has made his job easier, reducing the pressure to turn away ambulances during busy periods.

"In many places ER overcrowding is seen as an ER problem," he said. "We look at this as a hospital-wide and community problem."

Scott Allen can be reached by email at 

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