How EDs Can Limit Chronic Visits by the Homeless

Homeless Woman

This week I’m revisiting a blog post that takes a deep look at one of the biggest contributing factors to overcrowding in the emergency department — chronic visits by the homeless. Coordinating care with outside services, such as housing organizations, and other healthcare providers, can help meet the needs of homeless patients better, and thus reduce their use of the ED.

A few weeks ago, I wrote about how homelessness is one of two top causes of ED overcrowding. Today, let’s take a deeper dive into what experts think may help.

A recent study published last year in Psychiatric Services, a journal of the American Psychiatric Association, followed a cohort of more than 700 homeless individuals over a three-month period, tracking their use of the ED. Over the course of the study, 30 percent of participants visited the ED one or two times, which researchers deemed moderate use. Meanwhile, 12 percent visited three or more times, estimated as “high use.”

Researchers determined the reasons behind chronic ED use by the homeless were complicated.

Surprisingly, researchers concluded that housing status didn’t play a large role in chronic ED use. Homelessness wasn’t a cause in itself. Also, outside services did little to stem visits. However, the situation isn't totally hopeless. They found a possible solution lies in the cooperation of vested interests.

They contend that more coordination between outside services, housing organizations and healthcare providers “may better address the complex medical, housing, and psychosocial needs of chronically homeless individuals.”

“Increased ED utilization was associated with both general medical and psychiatric morbidity and greater use of non-ED services,” researchers wrote. “Thus ED use was related to high need and acuity and was not ameliorated by use of other services.”

So what does better coordination look like? Two recent news stories highlight how EDs and hospitals can better coordinate care with outside organizations to decrease ED use by homeless individuals. While these initiatives appear to be working, it’s still too early to gauge whether they’ll be sustainable in the long-term. But what they do show is how cooperation between outside organizations and healthcare providers can lead to better outcomes for homeless patients.

Finding respite in old motels

“It’s impossible for homeless people to recover from a health crisis when they just go back out onto the street after being discharged from the hospital. They end up returning repeatedly to emergency rooms and hospitals, which are very expensive.”

This story out of Buena Park, CA is a wonderful example of how coordinated care for homeless patients can better serve these individuals and positively impact a hospital’s bottom line.

The Illumination Foundation, a homeless services non-profit, has converted an old motel into a place of refuge for recently discharged patients. A triage center has been set up in the lobby and the rooms have been transformed into recovery facilities, with funding assistance provided by area hospitals and health insurers. Patients stay between two to three weeks and are able to obtain the social services necessary to help move them into more permanent housing. A nurse is even on staff.

And the program, still in its early stages, appears to be cost-effective—to the tune of $2,000 less per day than a hospital stay, which saves hospitals and insurers money. Patients, too, are experiencing positive results.    

“Housing first style” housing

“The hospital is paying to get them out of the emergency room and into housing.”

In Chicago, the University of Illinois Hospital has partnered with the Center for Housing Health to provide homeless patients an apartment and a case manager in order to curb chronic ED use. And it seems to be working.

Case managers help coordinate care by scheduling follow-up appointments, which lessen the odds of a return visit to the ED; and the apartments — which cost the hospital a third of what a hospital stay would — lessen the burden of homelessness on the patient and the healthcare system. And that’s not all. So far, with 15 patients in the pilot program, the initiative has helped lower healthcare costs for these patients by 75 percent, while having a positive impact on their health.

What these two programs highlight is how high-quality care doesn’t have to come at the expense of a hospital’s bottom line. What’s evident, is that investments in long-term solutions for the homeless and coordination of care pay off. Hospitals are able to increase the quality of care for all its patients — not just its chronic users who suffer from homelessness or mental and substance abuse issues — and cut costs.   

Is your hospital or ED working with an outside organization, or has a cutting-edge initiative it’s employing to counter the chronic use of the ED by the homeless? I’d love to hear about it. Feel free to comment below or drop me a line.



Psychiatry Services: “Factors Affecting Emergency Department Use by a Chronically Homeless Population”
Kaiser Health News: “Old Motels Get New Life Helping Homeless Heal”
Texas Public Radio: “A Hospital Offers Frequent ER Patients An Out — Free Housing”

How to Improve Care for Geriatric Patients in the Emergency Department

Doctor Talking To Senior Female Patient In Wheelchair

As the population ages and life expectancies increase, there’s now, more than ever, a need within emergency departments for care tailored specifically for geriatric patients. The U.S. Department of Health and Human Services’ Administration on Aging (AoA) notes more than 46 million people in the country are age 65 or older — over 14 percent of the entire U.S. population. That number is expected to rise to 22 percent by 2040 and double to 98 million people 65 and older by 2060.  

The health and well-being of this segment of the population will continue to be a concern for the healthcare industry as a whole, with emergency departments continuing to serve as an important point of access to care.

Currently, only 44 percent of men and women 65 and older characterize their level of health as excellent or very good, and most seniors have at least one chronic condition, if not more. According to the AoA, arthritis and heart disease were most common, with 49 percent and 30 percent of older Americans experiencing these conditions, respectively. Even more telling, nearly 7 million people age 65 and older spent at least one night in the hospital in 2014.

In collaboration with The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine, the American College of Emergency Physicians (ACEP) has developed a set of guidelines for EDs to follow to improve care for geriatric patients. If you’re an ED or hospital leader wanting to effectively refine the quality of care geriatric patients presenting to your ED receive, consider implementing these strategies as outlined by ACEP:

Staffing and Education

Emergency departments with high volumes of geriatric patients may want to consider employing dedicated staff and leadership trained in geriatric care. Depending on hospital resources, these positions could be filled with physicians and nurses with specialized training as well as ancillary service providers, such as occupational and physical therapists.

Education is another way to train your current team in understanding the needs of your elderly patients. Hospital leaders may want to consider developing  training programs to increase awareness among staff about how to provide the highest quality of care to geriatric patients or encourage staff to take part in continuing education or outside programs focused on geriatric care.

Follow-up Care

Effective communication is often key when it comes to patients — no matter their age — successfully receiving follow-up care after an ED visit. ACEP notes, “Older ED patients identify misinformation as a primary course of dissatisfaction with their emergency care, a problem confounded and magnified by ongoing under-recognition of cognitive dysfunction, lower health literacy, and financial impediments for prescriptions and recommended outpatient follow-up.”

When EDs ensure discharge instructions are relayed to patients and caregivers –– along with pertinent information about treatment and continuity of care –– geriatric care will improve significantly, and satisfaction will increase. ACEP recommends delivering the following facts, figures, and information to patients at discharge:

·      Presenting complaints

·      Test results and interpretation

·      ED therapy and clinical response

·      Consultation notes (in person or via telephone) in ED

·      Working discharge diagnosis

·      ED physician note, or copy of dictation

·      New prescriptions and alterations with long-term medications

·      Follow-up plan

·      Clinical information will be presented in a format in a way best suited for older adults

·      Large font discharge instructions

·      Health Insurance Portability and Accountability Act (HIPAA) compliant copied discharge instructions should be provided to family and care providers.


The type of equipment and supplies utilized by EDs have a great effect on the quality of care a geriatric patient receives. Consider making exam chairs more comfortable and accessible for older patients and using soft, moisture-proof upholstery. Special equipment such as warm blankets, non-slip mats, and walkers are also valued and appreciated by geriatric patients and their caregivers. Small touches such as painting the wall with light, non-glare paint, soft overhead lighting, and allowing natural light to fill rooms also go a long way to improve the well-being of elderly patients.

The benefits of improving the quality of care geriatric patients receive in your ED are great. EDs with care plans tailored for senior citizens can expect an increase in patient satisfaction scores, staff morale, and increased patient safety. I discussed just a few strategies hospital and ED leaders should take based on ACEP’s guidelines. If you’re interested in learning more about what your ED can do to serve geriatric patients better, feel free to schedule a complimentary phone consultation with me to discuss in detail additional steps you and your team may want to take.


U.S. Department of Health and Human Services Administration for Community Living: Administration on Aging (AoA) Aging Statistics

U.S. Department of Health and Human Services Administration for Community Living: Administration on Aging (AoA) Profile of Older Americans: 2015

American College of Emergency Physicians: Geriatric Emergency Department Guidelines

2 Factors Contributing to ED Overcrowding

This week I’m revisiting a blog post that discusses one of the most pressing issues facing emergency departments today — overcrowding. I discuss two of the biggest factors contributing to ED overcrowding — homelessness and boarding — and steps EDs can take to tackle the problem head on. These steps are especially important to consider as the holiday season and winter approach, which result in increased patient visits to the emergency department.

Overcrowding is the most pressing issue facing emergency departments today. When an ED is at — or over — capacity, quality of care, patient safety, and staff morale all begin to suffer.

EDs experience overcrowding for many reasons. While this blog focuses on two of the biggest culprits, it’s important to understand that a variety of factors, both internally within the ED and externally in the community, contribute to this growing problem.

Here are two of the most common issues contributing to overcrowding in the ED and a few suggestions to help EDs tackle the problem head on.

1. Homelessness

A 2002 study conducted by the American Public Health Administration found that more than 40 percent of the homeless respondents it surveyed had visited an ED at least once over the course of a year (Nearly eight percent visited on three or more separate occasions). Fast forward 10 years and not much has changed. This study from 2013found that single homeless women visited the ED 13 times more often than women in the general population. For single homeless men, the rate was nine times higher than the general population.

While homeless individuals make up a small fraction of the overall population in the U.S., the frequency of ED use by the homeless takes a toll when it comes to crowding.

What can EDs do? First, they must ensure that they have a strong patient flow process in place. Optimized patient flow is the first step to eliminating overcrowding, regardless of the cause.

Second, it’s important to build relationships with organizations within the community that can offer assistance to homeless patients once they’re discharged. Make sure you have a list of shelters, mental health and substance abuse professionals, food pantries, and other related organizations at the ready. Often, the most effective treatment is to empower patients with information on where they can seek assistance.   

2. Substance Abuse, Mental Health, and Psychiatric Boarding

Much like homelessness, patients battling mental health and substance abuse issues find themselves in the ED more often than the general population. In 2007, one in eight ED visits were made by adults with a mental health or substance abuse problem. The role of the ED is to perform emergency medicine, not provide long-term treatment for those patients suffering from these chronic problems. But in reality, EDs are on the frontline when it comes to treating the effects.

To help patients with mental health or substance abuse problems — and reduce the number of repeated visits to the ED — EDs should serve as a guide to outside resources and organizations that can offer long-term assistance. Just as with homeless patients — many who may suffer from mental health and substance abuse-related medical issues — the ED best serves as an intermediary.

The boarding, or holding for treatment, of psychiatric patients is another challenge contributing to the crowding of EDs. According to Dr. Scott Zeller, vice president and head of Emergency Psychiatry at CEP America in Emeryville, California, ED staff spend twice as much time trying to find in-patient beds for psychiatric patients as they do helping other patients. 

Dr. Zeller says, “Often these patients are kept with a sitter, or in ‘holding rooms’ or hallways on a gurney, some languishing for hours in physical restraints, often with no concurrent active treatment.”

As a solution, he recommends regional dedicated emergency psychiatric facilities that are EMTALA compliant. Patients could go to these centers on their own to seek care, be taken by ambulance when mental health is a concern or transferred there from hospitals that don’t offer psychiatric care once medically stabilized. They could be treated right away rather than spend hours waiting in an ED bed. 

Zeller’s suggestion is that the problem should be treated at the source — when patients first present –– rather than at the destination — once admitted to the hospital after hours of waiting and boarded in an ED. He sites that a great majority of psychiatric emergencies can be stabilized in less than 24 hours. In his model study, patient boarding times decreased significantly — by more than eight hours, an 80 percent improvement. 

These two factors that contribute to ED overcrowding have distinct characteristics that call for customized solutions. There’s not a single, universal course of action EDs can take to address overcrowding. Only by stepping back and taking into account all the factors at play can EDs begin to tailor a specific plan of action.

If your ED is facing issues related to overcrowding, Donovan+Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing, and patient flow as well as any external issues facing your community. Then we’ll help you implement the best solutions to alleviate crowding. Contact us today at or 651-260-9918. For more information on the services we offer, visit our website.


American Public Health Association: “Emergency Department Use Among the Homeless and Marginally Housed: Results From a Community-Based Study”

Science Daily: “Homeless people more frequent users of ED, other health services”

Medscape Medical News: “Mental Disorders, Substance Abuse Linked to Increased Emergency Department Visits”

Zeller, Scott: “Psychiatric Patient Boarding Problems in the Emergency Department”



How an Improved Patient Flow Process Makes Your ED Safer

Patient waiting a doctor in hospital

An optimized patient flow process offers several benefits for the emergency department. For example, efficient patient flow allows EDs to manage increased patient volume and throughput. It also reduces the costs incurred by EDs as a result of extended lengths of stay and boarding. EDs with an established and sound patient flow process experience higher staff morale and increased levels of patient satisfaction. Most importantly, improving patient flow increases patient safety in the emergency department, which is critical for ED and hospital leaders focused on patient experience.

We can all agree that emergency department crowding is, by and large, the greatest threat to patient safety. I discussed this correlation in a recent blog post, but I wanted to take some time to talk more about how an optimized patient flow process counters overcrowding and will lead to improved safety in the emergency department.

For patients experiencing life-threatening conditions— such as strokes, heart attacks and trauma — time is of the essence. Staff also must be able to have the confidence that bottlenecks or barriers to care do not appear when treating patients with these conditions. Inefficiencies in the ED may place undue stress on nurses, physicians and support and result in increased workloads, all of which pose a threat to patient safety. But when an optimized patient flow process is in place, ED and hospital leaders can be assured their patients will receive complete, comprehensive care without a risk to staff morale and patient safety.  

ED leaders must also understand the effects of bottlenecks and barriers to care in the ED can put a strain on other areas of the hospital, such as inpatient units. Rapidly admitting patients to inpatient units does little good if no beds are available. Efficiency isn’t really about the speed in which an ED admits, discharges or transfers a patient. It’s about providing quality care that’s appropriate while effectively managing the expectations of patients and their families along with relevant staff stationed throughout the hospital. If the ED is the front door of the hospital, it’s also where the flow of patients begins and the foundation for a culture of patient safety.

Delivering quality care promptly within the ED isn’t the only factor that contributes to this culture of patient safety. Effective communication and teamwork is also critical to patient safety and patient flow. Miscommunication takes an immense toll on an ED’s tally of preventable medical errors. If you’re an ED or hospital leader who has made the wise decision to revamp an inefficient patient flow process, make sure your communication strategy is tailored to the new plan. Communication is especially important during the implementation of any new or updated plan, no matter the performance areas you’re focusing on. Open-door policies, standardized communication practices and deep analysis of existing and potential communication structures are all proven strategies to increase patient safety and improve patient flow.

Need help improving your ED’s patient flow? Schedule a complimentary phone consultation with Connie Donovan to discuss what’s happening in your ED.


Agency for Healthcare Research and Quality: “Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals”

Agency for Healthcare Research and Quality: Patient Safety and Quality: An Evidence-Based Handbook for Nurses

How an Interim Management Consultant Adds Value to a Hospital and its ED

Two Consultants Discussing Patient Notes In Hospital

Emergency departments are complex care delivery systems with many interdependent components such as medical and support staff, inpatient and ancillary services and the community they serve.

CEOs, CNOs, COOs and CFOs rely on ED leadership and management teams to ensure clinical operations are aligned with quality and patient safety initiatives, value-based reimbursements and patient experience demands. And even though your emergency department may have great managers and directors on staff, it may need to be energized with temporary assistance. 

Working with an ED interim management consultant can help engage your current leadership team and bolster internal resources with additional experience and talent. ED interim management consultants are experienced emergency department leaders with deep clinical operational, financial and regulatory-accreditation experience. They support existing hospital management and leadership, providing clinical processes and tools to optimize what is working well. They also identify inefficiencies in the ED and then develop and implement practical, customized solutions to combat them. 

Whether it’s for one week or three months, the benefits and practical knowledge these consultants bring to the emergency department are immense. Here are a few ways interim management consultants add value to a hospital and its emergency department.

Improved clinical operational performance and patient experience.

Interim management consultants establish a strong foundation within your ED to strengthen clinical operations for value-based reimbursement. By focusing on staffing and scheduling effectiveness, as well as patient flow, they can improve clinical operations and heighten patient experience. Interim management consultants will also develop and implement a comprehensive and sustainable improvement plan and build upon current strategies to craft long-term improvements.


At times your hospital may have an ED management vacancy, which may result in unnecessary disruptions. By filling the vacancy with an interim management consultant, ED leaders can ensure continued progress on any initiatives and reduce the likelihood of any communication breakdowns. They can ensure that new, incoming managers are brought up to speed while providing stability to existing ED staff. They’ll also engage your team and openly communicate goals, actions, timelines and milestones.  


It’s important to act fast when filling an open leadership position, but finding the right person takes time. Interim management consultants allow you to devote more time and energy to finding the perfect permanent replacement. 

A fresh perspective.

Interim management consultants are often able to identify problems or issues that have previously gone undetected in an emergency department. The fresh pair of eyes interim management consultants lend to EDs can quickly spot inefficiencies in the patient flow process and any issues that could cause harm to patient safety initiatives. And, drawing from their vast experience in the field, they will be able to develop and implement innovative and creative solutions promptly.

Experience and solutions.

Even the highest-rated EDs have room for improvement, whether it’s a leaving without being seen rate that’s slightly above the national average or a bottleneck in the patient flow process that results in an unnecessary increase in lengths of stay. The best interim management consultants seek ways to strengthen these areas in the emergency department, maintaining high expectations when it comes to quality of care, patient satisfaction and patient safety – always ensuring that goals are aligned with their client’s business and patient care objectives. To do this, they draw from their wealth of experience to improve the quality of care EDs provide. 

When your current staff and leadership need a boost, or you experience a vacancy in your leadership team, interim management consultants like myself can help sustain the infrastructure of your emergency department while continuing to improve the patient experience. Donovan and Partners always keeps patient quality and safety in mind when working with emergency departments no matter their needs and the amount of time we spend with them. That’s why we work hand in hand with existing leadership to make transitions seamless and ensure operations continue to run smoothly, even when leadership positions are in question.

3 Ways to Identify At-Risk Patients in Your Emergency Department

Nurse having conversation with patient

Successfully identifying at-risk patients is a challenge facing many busy emergency departments today. These patients — who often suffer from substance abuse or mental health issues — need long-term care EDs aren’t equipped to offer. But in many instances, the treatment provided by emergency department staff and physicians is the only care at-risk patients receive, resulting in a revolving door of frequent ED use.

The first step to providing at-risk patients the care they need is to identify them as such. And for EDs looking to improve patient flow and reduce crowding, identifying at-risk patients is crucial. Connecting these patients with appropriate care providers in the community will lead to earlier diagnosis, ease access to treatment and increase the likelihood of a positive outcome for patients, all while reducing the odds of a return visit to the ED.   

Here are a few ways staff can identify and initiate care for at-risk patients presenting to the ED.

1) Conduct surveys. Short surveys, though simple in approach, are an effective way for EDs to identify at-risk patients. For example:

The ED at the University of Michigan Medical Center instructs patients — following an initial screening process to determine eligibility — to complete a five-question electronic survey to screen them for eating disorders. This survey has proven successful in identifying patients who screen positive for a potential eating disorder and found many of these patients to be frequent users of their ED. Once identified, proper treatment can begin and lessen the likelihood of a return visit by these patients.

2) Create a risk assessment tool. Risk assessment tools built into existing electronic medical record systems are a great example of how existing technology can help identify at-risk patients. The Denver Health Medical Center ED uses such a tool to gauge a patient’s risk of HIV to determine whether or not they should be tested.

“The tool covers three demographic and five behavioral risk factors, each of which is assigned a point value, with the cumulative score reflecting the patient's overall estimated level of risk,” a report published by the Agency for Healthcare Research and Quality states. “A triage nurse administers the tool during the patient intake process and documents responses in an electronic tracking system that calculates the score in real time.”

And if the patient’s score suggests a moderate to high risk of HIV, then rapid HIV testing is conducted followed by counseling and links to ongoing treatment.

3) Develop a safety plan for patients. For those patients at risk of suicide, veterans especially, it’s important for EDs to have a suicide assessment strategy and intervention plan in place. Many VA hospital-based EDs have these plans in place, though it’s equally important for other EDs to consider. When veterans or other patients are identified to be at risk for suicide but don’t require an immediate intervention, a safety plan can be developed to help patients overcome their thoughts of suicide along with assistance connecting to community resources to lower the risk of suicide.

Do you have similar plans in place to identify at-risk patients and initiate the care? If so, comment below to share your experience or feel free to drop me a line.  


SOURCES: Agency for Healthcare Research and Quality: “Emergency Department Uses Tool To Identify At-Risk Patients in Need of HIV Testing, Leading to Same Number of Newly Diagnosed Patients with Fewer Screening Tests.”

Agency for Healthcare Research and Quality: “Emergency Department Screening Identifies Many Patients With Possible Eating Disorders, Suggesting Potential to Facilitate Earlier Diagnosis and Connection to Treatment.”

Agency for Healthcare Research and Quality: “Emergency Departments Identify and Support Veterans at Risk of Suicide, Enhancing Their Access to Outpatient Mental Health Services.”

How Real-Time Analytics Will Revolutionize Patient Flow in Emergency Departments

Female doctor using ipad while working in hospital

A new and important tool has emerged to greatly improve patient flow in the emergency department (ED) — real-time analytics. By analyzing real-time data to predict potential surges in patient volume, EDs are able to take a proactive approach to optimizing flow. As a result, EDs are able to quickly alleviate crowding and improve the overall quality of care patients receive.

Brent Newhouse, co-founder and head of customer success at analyticsMD, is helping hospitals across the country streamline operations by leveraging real-time analytics. The use of analytics in hospitals is growing, he says, and the results are very promising.

How it Works

Most hospitals live in a reactive world and aren’t using real-time data and computer-driven models. To many the idea may sound futuristic, a little mysterious, a little like Moneyball. But without predictive and prescriptive analytics, hospitals can react, at best, only after an issue has presented itself. Even worse, ED leaders may not know a problem existed until weeks later, after the monthly report is generated, says Newhouse.

In the world of real-time data, predictive and prescriptive analytics can help shape the choices ED leaders make to improve patient flow in real-time. Those working in the ED can follow all this data on a dashboard setup on a computer.

How to Ensure Positive Outcomes

Being able to predict and anticipate a problem is the first step. Taking action based on that prediction is the only way to ensure a positive outcome. With real-time, data-driven models, ED staff are now able to know exactly when patients arrive; how many are waiting and for how long; and where their patients are in the treatment process at the glance of a dashboard.

What’s the Difference Between Predictive and Prescriptive Analytics?

Predictive analytics approximates when a potential surge in patients may be expected based on incoming data; while prescriptive analytics uses this data to provide a recommended course of action, explains Newhouse.

Predictive programs, such as those offered by analyticsMD, are able to determine when patient surges will take place — something that is harder for someone who wasn’t a quantitative math or statistics major to figure out in a moment’s notice. What a huge benefit considering that when EDs become overcrowded, it’s often too late to do something about it. The use of real-time analytics allows EDs to nip problems in the bud and better anticipate and avoid bottlenecks related to surges in patient volume.

For the prescriptive part, these programs can also recommend generally what actions can be taken to alleviate or avoid the issue altogether, which decision-makers can then take into account when making the final decision.

However, in my experience in managing EDs, I should note that, as a rule, prescriptive analytics is not as fully of a developed technology as predictive analytics is at this time. It is just harder for a computer to make some of the judgment calls that an experienced human can. So it’s good to remember that these programs are not meant to replace human decision makers — the experienced health professionals all EDs depend on. Rather they are intended to be tools that vastly improve the information decision-makers have at their fingertips. It can help folks on the ground so they can make wise decisions more quickly — saving time and improving quality of care. That, in turn, makes for happier patients and maximized reimbursements.  

Real-Time Tracking of Resources

Another benefit data analytics can offer your ED is resource management info. If there are certain resources within an ED that are being underutilized, data programs can identify those resources, so decision-makers can put them back into rotation. Empty rooms provide a good example. Real-time analytics can show which room is empty, how long it’s been empty for, and make a recommendation about which waiting patient might make the most sense to treat in it.

The Future of Real-Time Analytics in Healthcare

With this much power, the use of real-time analytics is sure to gain wider prevalence as hospital leaders catch on to its benefits. Currently, it’s proving most helpful in providing hospital staff with information to help optimize patient flow processes, providing quick, high-impact results. In time, the use of real-time analytics will likely begin to influence decisions within other areas of patient care. For now, think of it as a tool that can be leveraged along with other strategies to optimize operations in your ED.

Meshing Data and People

I briefly touched on this important point earlier — collecting all of this beautiful data and then implementing change based on it are two different steps. But you don’t have to take just my word for it. As Venkat Mocherla, director of business development & marketing at analyticsMD mentioned in a recent blog, “ … to get the most out of big data, you need to be able to work with the people on the ground to bring informed change to life.”

Mocherla was inspired in part by Randy Bean in recent Harvard Business Review blog called, “Just Using Big Data Isn’t Enough Anymore.”

“The vast majority of the challenges companies struggle as they operationalize Big Data are related to people, not technology: issues like organizational alignment, business process and adoption, and change management. Companies must take the long view and recognize that businesses cannot successfully adopt Big Data without cultural change,” says Bean.

Keeping this in mind, if you are investing in big data, I advise that it is worthwhile to also invest in getting a plan together for implementing change based on your learnings. This is because I have seen this challenge crop up at hospitals I’ve worked with in the past.  

If your organization is working to leverage big data to improve operations, I’d love to help. I’ve helped more than one ED create actionable steps and coached staff through the process. I can leverage my 20-plus years of experience to help you optimize patient flow and show you how doing that can lead to increased quality of care and patient satisfaction. Drop me a line at

Even if it isn’t an opportunity for us to work together this important step of creating and implementing an action plan is not one to be missed. You want to maximize the investment you’ve made in data collection. It’s just smart business.

And if you’d like to learn more about how real-time analytics can give your decision makers on the ground information that has the potential to improve patient flow within your ED, visit

3 Important Characteristics of Emergency Department Nurses and Why We Love Them


It’s easy to take emergency department nurses for granted. Even though they’re what I consider the eyes and ears of any busy ED, they don’t always receive the credit and appreciation they deserve.

Friday marked the beginning of National Nurses Week, reminding us to honor and celebrate these nurses who are so instrumental in providing safe, quality care in the ED. But what makes nurses so amazing? Here are just a few reasons to salute these hardworking women and men who are vital to a successful ED..

Uncommon Agility

You would be hard pressed to find any other profession where agility is so crucial to success. Being agile in an ED means always being on your toes, anticipating the needs of patients, their families and doctors. Agile nurses know what a patient or doctor needs before they themselves know they need it and the right questions to ask. Nurses in many ways have the keen ability to see in the future, which is vital when a life is on the line.

Superb Communication Skills

Anticipating the needs of patients, family members and doctors is one thing — being able to communicate with each of these very distinct groups is another.

First and foremost, great nurses are incredible listeners. They absorb directives from doctors that could easily be drowned out by the bustle of a busy ED. They also connect with patients and caregivers, listening to them in a way that help give the patient a voice in their care.

But listening is only half of communication. Nurses also have to speak with patients in a clear, concise way that’s easy to understand. One minute they may be talking to a 6-year-old boy with a broken arm, and the next, a 50-year-old man with an addiction to prescription painkillers. I can’t think of another profession where one communicates with so many different types of people, across so many demographics and socio-economic groups.

Enduring Empathy

Nurses care about the wellbeing of their patients — though they hope they never see them again, in the ED at least.

Empathy is the reason nurses are able to be considerate and sensitive when setting expectations regarding recovery. Empathy is also the reason why nurses return to work after a hard shift.

The strong sense of empathy that runs through each and every emergency department nurse isn’t always obvious, but we can rest assured it’s there — empathy is the reason nurses show up to work each and every day.

If the emergency department is the front door of a hospital, ED nurses are the ones making the very first impression and make sure that door is open to those who need it most.

One week really isn’t enough time to honor nurses and the important work they do, but National Nurses Week is a nice reminder for hospital leaders, doctors, patients and their families to show their appreciation for everything nurses do.

To learn more about what my company Donovan + Partners does, please check out our new website

Wait Times: How Does Your ED stack up?


Many patients might look at the emergency department (ED) like they would their neighborhood deli — first come, first serve. Luckily, for critically ill patients, this isn’t the case. The patients who need immediate treatment are going to receive it no matter how many patients are waiting.

Explaining this logic to a patient with a broken finger or a parent with a child experiencing cold symptoms may not be easy. The ED is the last place they want to be, and to them, their pain, or child’s pain, is a priority. Patients sometimes aren’t the best judge of their symptoms, and finding a way to get care outside of the ED can prove difficult depending on the day of the week, time of day and where they live.

The stats seem to reflect that. For example, from 2009 to 2010 more than 25 percent of all ED visits by children were for cold symptoms. For adults 12 percent of visits were deemed non-urgent, for cold symptoms and the like.

But it’s not just more non-urgent patients seeking care that are adding to wait times. With increasing numbers of patients visiting the ED for nonurgent conditions, wait times are bound to spike.

Year after year, average emergency department wait times have increased across the nation because visits are too. More people are seeking treatment at EDs — for urgent and nonurgent conditions — while the number of EDs is decreasing. According to the CDC the number of patient visits to EDs increased 32 percent over a 10-year period from 1999 to 2009. And at the same time many EDs closed their doors due to financial constraints.

So how does your ED’s average wait time compare?

One Measure: Broken Bones

The wait time for treatment of a broken bone is an important measure when it comes to hospital wait times. Of course, there’s different types of breaks and the severity of each will vary, but on average in 2014, a patient had to wait 54 minutes before receiving pain medications upon arrival in the ED.

For a national average, 54 minutes is long and depending on where a patient lives and which hospital they choose for treatment, the wait could have been much longer.

Take Washington, D.C. for example. Emergency departments in urban areas typically have longer wait times. In D.C., patients suffering from a broken bone had to wait an average of 69 minutes before receiving pain meds. This is only 15 minutes more than the national average, but with eight hospitals in the area the wait times varied drastically. If a patient sought treatment for a broken bone in D.C., they may have waited as little as 50 minutes for pain meds, or as long as 150 minutes depending on which ED they chose.

Difference in Wait Times Correlated to Patient Demographics

So who is facing longer wait times besides the no-critical patient? It seems adults go last and the old and the young are put first. According to the Centers for Disease Control and Prevention, Older patients, age 65 and older had the lowest mean ED wait time from 2008-2010 at 48 minutes. Children’s was 51 minutes And, adults 18 to 64 tended to have to wait the longest at 58 minutes.

Researchers found a difference when it comes to gender. Females experienced longer waits than males — four minutes more than men (57 minutes and 53 minutes, respectively).

There were even interesting stats around race. Non-Hispanic black patients experienced the longest wait times (68 minutes), while Hispanic patients waited 60 minutes, and non-Hispanic white patients waited 50 minutes.

What Will the Future Hold When it Comes to Wait Times?

On average they’ll increase, but there’s no reason your ED can’t be an outlier. First, you need to know where you stack up, which you can do by checking outProPublica’s ER Wait Watcher.

If you find that your patients are waiting longer than those at a nearby hospital, Donovan and Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing and patient flow, and then help you implement the best solutions to cut wait times. Contact us today at or 651-260-9918.


ProPublica: “ER Wait Watcher, Which Emergency Room Will See You Fastest?”

Centers for Disease Control and Prevention: “Wait Time for Treatment in Hospital Emergency Departments: 2009.”

Centers for Disease Control and Prevention: “Health, United States, 2012, With Special Feature on Emergency Care.”

American College of Emergency Physicians: “Emergency Department Wait Times, Crowding and Access Fact Sheet.”

How to Boost Emergency Patient Satisfaction and Lower Costs

Happier patients and a better budget? It’s not too good to be true. Whether it’s long wait times or something else dragging down your patient satisfaction scores, you can take steps to give people a better experience. Chances are these moves can be good for your bottom-line too.

1) Slow Down and Listen

How to Boost Emergency Patient Satisfaction and Lower Costs.jpg

Encourage doctors and other staff to take their time when they talk with patients. This may sound counterintuitive. Slow down when things get stressful and busy? When health care providers keep patients up to date on what they are thinking in their decision making process, patients report a better experience. It can also encourage patients to share information that may help doctors make the right diagnosis and only order necessary tests, saving everyone money. This is especially the case because, by at least one estimate from the Centers for Medicare & Medicaid Services, nearly half of all emergency department (ED) bills go unpaid.

2) Provide Patients With Follow-Up Instructions and Make Nurse Calls

When your hospital staff has information they easily can pass along to patients about how to care for themselves and take prescriptions, it improves the chances of recovery. One study found a link between whether patients get better and their satisfaction. It makes sense. They went to the emergency department to get fixed. Did you help them make that happen? It not, they may wind up in your emergency department again. Repeat visits add costs. This can be especially costly if they are uninsured and unable to pay.

Older patients and people who live alone may benefit from a follow-up call from a patient navigator. These nurses can make sure that patients are following their aftercare instructions. They can also encourage them to seek follow-up care with their primary care doctor or give them information on other places where they can find medical care on an ongoing basis.

3) Develop a Plan to Cut Crowding

This is often the number-one problem emergency departments face. It causes long wait times for patients to be seen and before they can get discharged. That’s often a top patient complaint. Crowding can also compromise quality of care, according to the US Department of Health and Human Services. It also puts strain on the staff.

The best way to tackle the issue of crowding is to make a plan. It’s likely that you can make improvements in a few areas and yield budget savings too by creating efficiencies.

The Agency for Healthcare Research and Quality suggests that you form a patient flow team to examine the whole patient experience process from check-in to discharge. The team should ideally include members from across the hospital. Doing that makes sure no part of the process is left out. Plus, it creates buy-in. When people are involved in the planning, they are better at communicating changes and more likely to follow them.

Once the team is formed, you'll work together to focus on the areas that need fixing and putting your plan into action. Ways to measure if goals are being met and celebration of successes are key to making these plans pay off.

4) Know Your Patients and Hire Allied Health Professionals

Mid Level medical staff members can help patients have a better experience. When an ED is staffed up properly, Physician’s Assistants and Nurse Practitioners can provide timely patient screening and develop a rapport with the patients.

These allied health professionals are especially helpful to evaluate incoming emergency patients and triage them for emergency or minor care. You want to be able to quickly figure out what your patients need and match them with the right providers for the right service. They can also be the ones to provide care for less complicated cases.

Remember that if you do need to make new hires, another bonus is that these health professionals are more affordable than doctors. If you don't feel equipped to make the case for extra staff, you can look to outside consultants to help you pull the right data and produce justification reports. Sometimes spending some money upfront can make savings down the road. Consultants can also help create a patient flow plan.

5) Develop Short-Stay Clinical Services

Not all patients who come in to the ED need to admitted to wait for lab results or stay in a bed to be observed. When it's not necessary, it can feel awkward for the patient and be expensive for them, their insurance company (if they have one), and your hospital.

Under the new healthcare law, Medicare can reduce or cut reimbursements for unneeded stays. Admitting these patients can also take up valuable bed space from someone in the waiting room who really needs it.

Instead, you may want to create two types of waiting areas for patients who have been evaluated but don’t need to be admitted. One can be as simple as a nice waiting room with reclining chairs. Some people call this a results waiting room. Patients who don’t need a bed but are waiting on things like X-ray results can wait here.

The second type is an observational unit or clinical decision unit. Patients who would go here are also waiting on results but may need a little bit of treatment and a bed. However, they don’t need to be admitted upstairs. Patients who need to be watched for things like low-risk chest pain, asthma, or dehydration can stay there and keep costs down.

For more ideas on how to improve patient experience while helping your budget, reach out to us. We'd love to talk about how we can help.


ECI Healthcare Partners: “How to Cut Emergency Costs Without Compromising Quality of Care,” “Boost Your Patient Satisfaction Scores.”

American Academy of Family Physicians: “What Do We Really Know About Patient Satisfaction.”

Agency for Research Quality and Assurance: “Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals.”

The Centers for Medicare & Medicaid Services: “Reducing Nonurgent Use of Emergency Departments and Improving Appropriate Care in Appropriate Settings.”

Beth Israel Deaconess Medical Center: “Observation Medicine - Clinical Decision Unit.”

University of Maryland Medical Center

The Commonwealth Fund: “Achieving Efficiency: Lessons from Four Top-Performing Hospitals.”

RINPR: “No Easy Task: "Reinventing" Medicaid To Improve Health, Contain Costs.”

American College of Emergency Physicians: “Emergency Department Observation Services.”

The Hospitalist: “Pros and Cons of Clinical Observation Units.”