How Electronic Health Records Improve Patient Care in the ED

Administrative Nurse

The use of electronic health records (EHRs) in the emergency department can be a critical step in the process of improving overall patient care. EHRs are a great example of how embracing new technology can provide long-term benefit to patients and staff, despite the short-term woes that may present themselves during implementation and integration. (Some hospital leaders, ED physicians and staff have, rightfully so, been hesitant to switch over to EHRs because of these short-term challenges. Nonetheless, the positives appear to outweigh the negatives in regard to electronic health records.)

Let’s look at a few benefits of electronic health record systems and how using them can improve patient care in emergency departments.

Easy Access to Patient Information

Getting a patient’s vital medical information is quick and easy thanks to EHRs. All the information you need to provide quality care in a timely manner to your patients is available in one digital location. Important information such as past medical history, immunizations, lab data and medications are right at your fingertips. And most importantly, the frustration of trying to decipher another healthcare provider’s handwriting is no longer a worry.

Clinical Decision Support

Clinical decision support (CDS) systems can be integrated into EHR systems to help providers make decisions on patient treatments, prescriptions and overall patient care plans. So what is a CDS?

“Some functionalities of a CDS system include providing the latest information about a drug, cross-referencing a patient allergy to a medication, and alerts for drug interactions and other potential patient issues that are flagged by the computer,” cites a reportpublished in the Journal of Risk Management Healthcare Policy. “With the continuous growth of medical knowledge, each of these functionalities provides a means for care to be delivered in a much safer and more efficient manner.”

Computer Physician Order Entries

Thanks to computer physician order entry (CPOE) systems, medical errors stemming from illegible or incomplete drug and lab test orders can be reduced. CPOE systems combined with electronic health record and clinical decision systems harness the efficiencies of each to reduce the potential for error and provide patients more efficient and higher quality care.

Health Information Exchanges

Health information exchanges (HIE), which share patient information between providers, allow for a continuity of care that pen and paper are unable to provide.

“Over a lifetime, much data accumulates at a variety of different places, all of which are stored in silos,” researchers note. “Historically, providers rely on faxing or mailing each other pertinent information, which makes it difficult to access in “real time,” when and where it is needed. HIE facilitates the exchange of this information via EHRs, which can result in much more cost-effective and higher-quality care." Just as easy access to patient information within the ED can improve care, providing this ease of access across the spectrum of healthcare providers will have a ripple effect that positively impacts the industry as a whole.

But implementing EHRs in the ED is no easy task. It’s daunting to switch systems while still being expected to provide the same high quality of care your patients deserve and are accustomed to. The benefits of EHRs, however, are promising and have the potential to dramatically improve patient care within the emergency department while lowering costs across the board. As the long-term effects of EHR use are studied, improvements in the implementation and integration of this digital technology will surely follow.

How has your ED fared when it comes to utilizing electronic health records? What benefits are you seeing? Feel free to drop me a line or comment below

SOURCES: Journal of Risk Management Healthcare Policy: “Benefits and drawbacks of electronic health record systems.” “Benefits of Electronic Health Records (EHRs).”

Do Return ED Visits Signal Lower Quality of Care?

When a patient makes a return visit to the emergency department, you may draw the conclusion that quality of care the first time wasn’t great. But a study recently published in the Journal of the American Medical Association offers data that may contend otherwise.

The study’s authors acknowledge that return visits to the ED “are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care.” So they set out to find whether or not these return visits, which led to in-patient admission, were evidence of a lower quality of care from the ED that initially treated the patient. The pervading question being, that if a patient is ultimately admitted to the hospital, shouldn’t it occur during their first visit to the ED, and not the second or third?

Researchers looked at in-hospital mortality, intensive care unit admission, length of stay, and inpatient costs to determine whether a patient returning to the ED was a reliable measure of quality of care within that ED. The results were surprising.

“Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay,” researchers concluded. “These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.”

Let’s look closely at the numbers. Patients discharged from an ED and subsequently admitted to the hospital upon a return visit experienced:

  • An in-hospital mortality rate of 1.85 percent vs. 2.48 percent for those patients admitted during their initial visit to the ED.
  • An ICU admission rate nearly six percent less (23.3 percent vs 29 percent).
  • The cost of care for these patients was also less ($10,169 vs. $10,799), even though their length of stay was slightly higher (5.16 days vs. 4.97 days).

And for those patients admitted to the hospital within 14 and 30 days of their ED visit? Similar outcomes were experienced.

But what about those patients readmitted to the hospital after hospital discharge and a return visit to the ED?

“In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit,” researchers found.

What do you think? Are return visits to the ED an adequate measure of quality of care? Please comment below or feel free to drop me a line.

The Journal of the American Medical Association: “In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department”

Opioids: Which Intervention Works Best in EDs?

Distressed Patient

Emergency departments are on the front lines of the opioid epidemic. EDs have everything to gain by doing more than just stabilizing patients or denying prescriptions. A more proactive approach can not only help the patient but can improve long wait times, overcrowding and low patient satisfaction.    

EDs can begin the intervention process for patients presenting with symptoms of opioid dependence. A study published last year in the Journal of the American Medical Association looked at three interventions and their efficacy.

3 Intervention Approaches and Their Effectiveness

1. Referral
This study involved over 300 opioid-dependent patients at an urban teaching hospital, each randomly assigned to three types of intervention, and studied over the course of 30 days. After screening, this first group was provided a handout with names, locations and telephone numbers of local treatment services, which varied by type and intensity. Patients were also allowed to call a clinician or treatment facility of their choice from the ED. By merely providing patients with information and tools for treatment, researchers saw that 37 percent of participants were engaged in addiction treatment at the 30-day mark.

2. Brief Intervention
In this group, patients received a brief negotiation interview (10 to 15 minutes) from a research associate containing four components:

  •      Raise the subject.
  •      Provide feedback.
  •      Enhance motivation.
  •      Negotiate and advise. 

Treatment options were then discussed, with similar information provided that those patients in the referral group received. With this more focused intervention, 45 percent of patients were engaged in addiction treatment at the 30-day mark.

3. Buprenorphine Treatment
In this final group, patients received the same brief negotiation interview as those in the brief intervention group received. If symptoms of moderate to severe opioid withdrawal were apparent, then ED-initiated treatment with buprenorphine was started. Patients were given enough medication to take home until an appointment in the hospital’s primary care center, when a 10-week course of treatment of buprenorphine was introduced. At the conclusion of the 10 weeks, patients continued treatment in a community program, clinician-lead program or a two-week detox program.

At day 30, 78-percent of patients were still engaged in addiction treatment and illicit opioid use dropped from 5.4 days per week, to just under one. (The referral group saw a reduction of illicit opioid use to 2.3 days per week and the brief intervention to 2.4 days per week.)

All three interventions increased engagement in treatment for opioid-dependent patients, but it’s clear a more intensive, hands-on intervention with medication treatment offered to this study’s third group proved more effective. The authors say that there still needs to be more studies.

Does your ED have an intervention strategy it implements for opioid-dependant patients? If so, I’d love to hear about it. Please comment below and share what has or hasn’t worked for you or feel free to drop me a line. If you’d like an assist with fine-tuning your ED's operation, no matter which challenges you’re facing, check out my company’s website to see if we may be a fit for you.


The Journal of the American Medical Association: “Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence.”

How Patient Obesity Affects Emergency Departments

Obese Patient

The Centers for Disease Control and Management describes obesity in three words: Common. Serious. And costly.

Nearly 80 million adults in the United States are obese and the list of adverse health effects related to obesity are long — think heart disease, stroke and type 2 diabetes, to name a few.

And the cost? According to the CDC, the healthcare costs associated with obesity was nearly $147 billion in 2008.

In emergency departments across the U.S. patient obesity presents an array of challenges for doctors, nurses and staff who manage care. Physical exams are more challenging as rolling the patient is more difficult, and examining the patient’s whole body can be difficult.

A study published in Emergency Medicine Australasia concurs, noting that when treating obese, and morbidly obese patients, measuring blood pressure, inserting IVs, positioning patients and performing other medical procedures are all increasingly hard.

“BMI most strongly correlated with difficulty in finding anatomical landmarks, venous pressure measurement, physical examination, patient positioning and procedures generally, especially cannulation and venipuncture,” the report concludes.

EDs, doctors, nurses and staff have countered these challenges with common sense solutions. EDs turn to things such as lifting equipment; larger blood pressure cuffs and beds; and increased staff to help with mobilization and positioning. While these extra initiatives come with a price tag, they all are necessary to provide the quality of care patients who are obese deserve when visiting the ED.

However, surprisingly, whether patients are obese or not may not have a serious impact on average length of stay. In a 2005 study published in Academic Emergency Medicine, researchers were surprised to find that obese patients and non-obese patients presenting to the ED with abdominal pain had similar experiences:

  • Length of stay for obese patients was 457 minutes, while non-obese patients LOS measure higher at 486 minutes.
  • 3.2 laboratory studies were conducted for obese patients versus 2.9 for non-obese patients.
  • Rates of consultation were four percent less for obese patients
  • Admission rates were six percent lower for obese patients.

Does this surprise you? What strategies has your ED implement to better treat patients who are obese? Please comment below or feel free to drop me a line

Centers for Disease Control and Prevention: “Adult Obesity Facts.”

Emergency Medicine Australasia: “Obesity significantly increases the difficulty of patient management in the emergency department.”

Academic Emergency Medicine: “Obese patients with abdominal pain presenting to the emergency department do not require more time or resources for evaluation than nonobese patients.”

How EDs Can Limit Chronic Visits by the Homeless

homeless woman

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 Psychiatry 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% of participants visited the ED one or two times, while 12% visited three or more times, which researchers deemed “high use.”

What researchers determined was that the reasons behind chronic ED use by the homeless were complicated.

Surprisingly, researchers concluded that housing status didn’t play a large of a 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”

2 Non-Opioid Pain Treatments to Try in Your ED


Laughing gas. Acupuncture. Energy healing. Music therapy. These are just a few of the alternative pain treatments being used in emergency departments today to help curb the opioid epidemic.

With the Center for Disease Control’s recent recommendation that primary care providers should try “nonpharmacologic and nonopioid therapies” prior to prescribing narcotic pain relievers to patients, it’s now time for EDs across the country to begin exploring other pain relief options.

For many patients, their first introduction to powerful pain relievers begins in the ED. Medications such as Percocet and Vicodin provide swift and efficient pain relief, but for some, the social, economic and health costs prove too great. Possible dependence and death are just two of the consequences.

So what can emergency departments do to help curb opioid use and dependence? I recently wrote about a few strategies EDs can implement to combat the opioid epidemic. One strategy not mentioned was the use of alternative therapies, which is beginning to catch on as recent news reports and studies highlight their potential efficacy.   

The New York Times recently profiled the emergency department at St. Joseph’s Regional Medical Center in Paterson, NJ, which is ahead of the curve when it comes to providing alternative therapies for patients presenting with chronic or acute pain.

The story highlights St. Joe’s use of a variety of alternative pain relief techniques, such as nitrous oxide and non-opioid analgesics, to reduce its reliance on opioids, while still providing effective pain relief to its patients.  

“In five months, the hospital has reduced opioid use in the emergency department by 38 percent. St. Joe’s has treated about 500 acute pain patients with non-opioid protocols. About three-quarters of the efforts were successful.” — The New York Times

Success like that warrants deeper investigation so let’s look at two alternative therapies St. Joe’s, and other EDs in the U.S., are using to provide quality care and pain relief to its patients.

1. Nitrous Oxide

Nitrous oxide, better known as laughing gas, has a long history of delivering safe, non-addictive pain relief. As described by the Times, it’s “short-acting, mildly sedating, noninvasive and has countless applications in the ER.” There are few things that can put a smile on a patient’s face while they have a dislocated joint manipulated back into place.  

In a report published in the Emergency Medicine Journal nearly 15 years ago, nitrous oxide is described as having all the characteristics of an “ideal analgesic agent.” It’ safe, predictable, non-invasive, free from side effects and simple to use with rapid onset and offset.

And here are a few instances, according to this report, where nitrous oxide may prove effective:

  •      Relief of pain from musculoskeletal injuries
  •      Reduction of joint dislocations
  •      Adjunct to other analgesia in forearm fracture manipulation
  •      Adjunct to lignocaine (lidocaine) in laceration repair
  •      Adjunct to other analgesia in wound care and abscess drainage
  •      Myocardial chest pain
  •      Migraine

So why are we now just rediscovering the benefits of nitrous oxide for treatment of pain? As this 2002 report notes, newer approaches were threatening its use. One can only think, those “newer approaches” were being delivered in the form of opioids.  

2. Acupuncture

Like nitrous oxide, the use of acupuncture within the ED setting is proving to be an effective alternative to opioid pain relievers.

Take the emergency department at Abbott Northwestern Hospital in Minneapolis, Minn. as an example. Two years ago, it was the first ED in the country to have an acupuncturist on staff, and in March of this year the Star Tribune reported “that pain scores in those who received acupuncture alone dropped by the same amount as those who also received analgesic painkillers.”

While studies regarding the effectiveness of acupuncture as a pain reliever are inconclusive, it does “show promise” in alleviating pain among patients in the ED and may be a safe alternative to opioids. Researchers, the Star Tribune reports, hope to prove conclusively that acupuncture relieves pain, reduces costs and should be covered by insurers.

Nitrous oxide and acupuncture are just two alternatives to being used by emergency departments today to limit opioid use and dependence. The results and stories of success are promising, but it will take more than just a simple adoption of these strategies to curb the opioid epidemic. As the stories from St. Joseph’s and Abbott show, emergency departments, and the healthcare industry as a whole, will have to transform the culture of care and pain management to reduce the reliance on opioids.

If you’re interested in learning more about the role emergency departments can play in fighting the opioid epidemic, don’t hesitate to drop me a line. You can also visit the Donovan + Partners website to learn more about the services we offer.

Centers for Disease Control and Prevention: “CDC Guideline for Prescribing Opioids for Chronic Pain | Guideline Information for Providers.”

The New York Times: “An E.R. Kicks the Habit of Opioids for Pain.”

American Academy of Pain Medicine: “Acceptability, Adaptation, and Clinical Outcomes of Acupuncture Provided in the Emergency Department: A Retrospective Pilot Study.”

The Star Tribune: “Abbott pioneers acupuncture in the ER.”

Emphasize Teamwork and Communication to Increase Patient Safety

Nurses Consulting

The potential for risk is great in emergency departments. In the hospital setting, EDs rank as high-risk as intensive care units and operating rooms. In all three of those settings, staff members have to work together and communicate clearly to ensure patient safety.

EDs that place a strong emphasis on teamwork, and have in place an effective communication strategy, are able to counteract the inherent risk associated with a patient’s visit to the ED.

Previous studies in health care settings indicate that upwards of 80 percent of medical errors are related to “interpersonal interaction issues,” or more simply, miscommunication. By placing a focus on teamwork and effective communication, an ED will increase not just patient safety, but patient satisfaction, quality of care and staff morale.

Check out these three ways to improve communication and increase teamwork within the emergency department:

1. Implement an Open Door Policy

Effective leaders flatten the hierarchy, create familiarity and make it feel safe to speak up and participate.  — M. Leonard, S. Graham and D. Bonacum

Within EDs, it’s crucial that staff feel comfortable bringing concerns and ideas to their immediate supervisors and those in charge. A sense of strict hierarchy and power structure can discourage your staff from speaking up, but open door policies can counteract those effects and improve communication and enhance teamwork among staff.

2. Standardize Practices

The lack of standardised communication and procedures in medicine increases the importance that team members invest in creating a common mental model; otherwise, there is limited ability to predict and monitor what is supposed to happen. — M. Leonard, S. Graham and D. Bonacum

In many EDs, staff members possess varied levels of experience and responsibility, as well as different personalities and beliefs. To improve communication and foster an environment centered on teamwork among such a diverse group, start by standardizing procedures, practices and communication models. By emphasizing structure within those methods of care, ED staff will all be on the same page and know how and when to communicate concerns or other vital information to their colleagues and those in positions of authority.

3. Be Deliberate

Communication failures are the leading cause of inadvertent patient harm. Analysis of 2,455 sentinel events reported to the Joint Commission for Hospital Accreditation revealed that the primary root cause in over 70% was communication failure. Reflecting the seriousness of these occurrences, approximately 75% of these patients died. — M. Leonard, S. Graham and D. Bonacum

As an ED or hospital leader, when you focus on communication and teamwork, in many instances, you will be changing the culture of your ED. Although the correlation that exists between patient safety and effective communication and teamwork is strong — and benefits, such as improved quality of care and increased patient satisfaction will result — a long-term strategy should be used to implement changes because this type of change takes time and dedication. It’s wise to conduct a deep analysis of every new strategy incorporated, since each step of the process has influence on the overall course of action. Be deliberate and create a schedule with the help of your staff to increase effectiveness.

The positive impact on patient safety, quality of care, patient satisfaction and staff morale that result from improved communication is something I’ve witnessed in many of the EDs Donovan and Partners has had the pleasure of working with. If your ED could benefit from improved communication and enhanced teamwork, feel free to get in touch. Contact Donovan & Partners today at or 651-260-9918. I'd be happy to do a personalized assessment of your ED and provide actionable solutions. For more information on the services we offer, visit our website.

Nursing Economics: “Measuring teamwork and patient safety attitudes of high-risk areas.”

BMJ Quality and Safety: “The human factor: the critical importance of effective teamwork and communication in providing safe care.”

Troubleshoot Triage to Improve Patient Flow

Emergency Waiting Room Donovan Partners

Seven years ago — from December 2008 through February 2009 — approximately 13 percent of patients who visited the emergency department at Hahnemann University Hospital in Philadelphia left without ever being seen. Over a three-month time period, the 31-bed ED had more than 8,800 visits — overcrowding was a significant problem.

The very next year, over the same three-month time frame, Hahnemann’s ED saw almost 800 more patients — close to nine more per day — but the LWBS rate dropped significantly. Even with the increased patient volume, the ED’s LWBS rate decreased by more than three percent. Three months later, the LWBS rate had dropped even lower to six percent.

But how?

In June 2008, Hahnemann’s ED leadership made a commitment to improve patient flow, and soon partnered with the Urgent Matters Learning Network II — a 6-hospital collaborative that worked with one another to improve patient flow and alleviate overcrowding. Through the consortium, they were able to develop a triage process that worked for their specific hospital given its size, staffing structure and urban location. (ED leaders at Hahnemann ultimately decided to implement the ESI 5-level triage system; introduce a policy of bringing patients to an open bed for triage and registration; and dedicate resources, staff and space for patient fast tracking. And it worked.)

For Hahnemann, implementing an improved patient flow process at triage resulted in lower LWBS rates, less overcrowding and increased morale among its staff. Higher patient satisfaction scores soon followed.

A more recent example of what can result when an ED prioritizes patient flow is Florida Hospital Tampa (FHT), an ED that had been experiencing a nearly 40-percent annual spike in patient volume as it suffered from a 21-percent staff turnover rate. And if that wasn’t enough, patients were ranking its doctors in the bottom ninth percentile nationwide.

An analysis by the Healthcare Financial Management Association outlines how FHT was able to develop and implement a flexible patient flow process combining two proven strategies: team triage and immediate bedding. Dubbed Doc1stER, the new patient flow triage strategy produced quick results — after two months FTH was the most improved ED in its 41-hospital system.

No two EDs are the same and strategies to improve patient flow aren’t one-size-fits-all — staffing, location and space are just a few factors that have to be considered. ED leaders wanting to improve patient flow triage need a plan tailored specific to their ED. With a proven record of being able to identify and develop patient flow strategies, Donovan and Partners can help you examine and improve your current triage process, and then help you implement a plan to improve patient flow in your ED. Contact us today at or 651-260-9918. To learn more about the complete set of health care consulting we offer, please visit


Healthcare Financial Management Association: “7 Tips for Improving Emergency Department Patient Flow.”

Hospitals in Pursuit of Excellence: “Improving ED Flow through the UMLN II.”

3 Strategies to Improve Emergency Department Communication

Group of Nurses and Doctors Donovan Partners

A single breakdown in communication within your emergency department can mean dire outcomes for patients. Consistent breakdowns may even lead to a significant decrease in staff satisfaction, patient satisfaction and overall quality of care.

The way in which information is relayed between staff, patients and caregivers is one of the most important aspects of the treatment process — one that should always be scrutinized and improved upon. By placing an emphasis on effective communication, EDs can expect better and safer quality of care, more satisfied staff, and increased patient satisfaction scores.

Here are three strategies to help improve communication within your ED.

1. Huddle Up

Many EDs experience communication breakdowns during shift changes. Short team meetings before the start of a shift are a great way to promote teamwork and make sure everyone coming on is on the same page at the start of the shift. And if time and circumstances allow, organize another less formal “spot” meeting mid-shift to tackle any foreseeable concerns.

A 2009 Stanford study found short, pre-shift staff huddles were instrumental in fostering teamwork and communication within the ED. Researchers concluded that the positive perception of and “compliance with collaborative decision making” increased after implementing huddles, and, in all likelihood, would lead to higher levels of staff satisfaction and better patient outcomes.

2. Know When Not to Embrace Technology

The ways in which we communicate with one another is ever-changing. New technologies emerge only to be replaced by something different soon after. It’s often tempting to become an early adopter of tech, believing it holds the solution to your problem.

However, the ED isn’t usually the best setting to try untested, new technologies — there’s too much at stake. Here’s a great example:

In 2012, a panel of healthcare providers came together at George Washington University to discuss the role of technology in the ED, highlighting several instances where the implementation of new technology provided no benefit to the provider or the patient. One provider noted how using computers instead of white boards led to a breakdown in communication among staff.  

Swapping a white board for a computer, in some cases, meant losing valuable communication tools used among ED nurses and technicians that seemed negligible to the outsiders who transitioned the data.

The old adage, “if it ain’t broke, don’t fix it,” definitely applies here. Maybe that’s why we’re one of the only professions left using pagers.

3. Identify the Barriers to Effective Communication

When do communication breakdowns occur? And where along the treatment process do they occur? In order to be able to improve communication within the ED, identifying the problem areas is the first step you need to take. Only by identifying the barriers to effective communication will you be able to implement a targeted plan to overcome those obstacles.

Also, it’s important to remember that effective communication strategies should be employed hospital-wide. Some of the most effective communication strategies are born out of EDs. That’s because stress and burnout can flourish in the ED and poor communication fuels it. Good communication is a must to keep those at bay and be able to operate effectively. Communications techniques that do well in the ED have been battle-tested.

If you can employ effective communications strategies within your ED, you can serve as a model for other departments, improving communication throughout the hospital, and maybe even system-wide.

Bottom line: when you are aware of the obstacles present within your ED that are inhibiting effective communication, you’ll be able to develop a course of action for your overall communication strategy that will benefit your ED and hospital patients, staff and budget.

If you could use a hand to pinpoint the barriers to effective communication within your ED, or need assistance implementing strategies to improve communication, don’t hesitate to drop me a line. Contact Donovan & Partners today or 651-260-9918. I'd be happy to do a personalized assessment of your ED and provide actionable solutions. For more information on the services we offer, visit our website.

Heather Tilson, RN, BSN & Angela Vega, RN, MSN, CNL, CRNI & Garrett K. Chan, APRN, PhD, FPCN, FAEN: “Improving Teamwork and Communication in the Emergency Department.”

George Washington School of Medicine & Health Sciences: “Technology in the Emergency Department.”

3 Ways to Lower LWBS Rates in the ED

Patient Walking Away Donovan & Partners

There can be profound consequences for patients, emergency departments and the healthcare industry as a whole when patients leave an ED before they receive treatment. For patients, delayed treatment can mean sustained illness, pain and even death. For hospitals, high rates of patients leaving without being seen (LWBS) signify a loss of revenue. And for the healthcare industry, when patients seek treatment but don’t receive it, questions regarding appropriate access to care arise.   

The rate at which patients will leave an ED without being seen varies sharply from one hospital to another. In one report published in 2011, researchers looked at patient-visit data from 262 hospitals and found LWBS rates as low as .1 percent and as high as 20.3 percent — a tremendous variation. (The median rate was 2.6 percent.)

The reasons why one hospital may see upwards of one fifth of their patients leave without receiving treatment while another is able to treat almost all of the patients that enter its doors is just as varied. These same researchers offer a few explanations as to why there may be high walkout rates:

  • Hospital restructuring and market factors, including the increased number of EDs that have closed their doors.
  • The possibility that hospitals in lower-income areas may be closing at a higher rate, causing more vulnerable populations to have less access to care.
  • Increased wait times and ED crowding.

It’s important to mention that this study noted hospitals that served a high proportion of low-income and poorly insured patients had disproportionately higher LWBS rates. (Researchers found that the odds of a patient leaving without being seen fell by a factor of .86 for each $10,000 increase in household income.)

With this in mind, what can a hospital do to lower LWBS rates within its ED?

To lower LWBS rates, ED leadership must first identify the reasons why LWBS rates are increasing. Is it because of overcrowding or inefficient patient flow? Did a nearby ED recently close and now you’re seeing an influx of patients? Is your ED properly staffed? Once you identify the causes then you can tailor a plan of action.

Here are a three examples of what EDs have done to curb rising LWBS rates:  

1. Triage is a process, not a location.

In 2011, Illinois’ Elmhurst Hospital moved to a new campus four miles west of its former location. As a result, nearby Gottlieb Memorial Hospital in Melrose Park became the closest hospital for many patients and ambulances in the area. Naturally, due to Elmhurst’s move Gottlieb experienced a surge in average monthly volume — from 1,800 to 2,100 patients — and with that, a 10 percent LWBS rate.

To combat such a high LWBS rate, hospital leaders at Gottlieb implemented a “pull till full model,” redefining triage as a process rather than a location. Nurses were instructed to immediately lead patients to empty rooms and conduct the triage process at bedside. Six months later, Gottlieb’s LWBS rate plummeted to just below four percent thanks to the strategy and other sound initiatives, such as the evaluation of staffing patterns among its nurses and physicians.

2. Communicate with other departments.

In 1999, the ED at Miami Children’s Hospital had a LWBS rate of 5 percent. Its average throughput time was 3.5 hours and patient satisfaction scores were dismal. Over the course of four years, through a series of innovative changes implemented by ED leadership, the ED’s LWBS rate dropped to 1 percent with a nearly one-hour decrease in average throughput time. (Its patient satisfaction scores went from being in the 35th percentile to the 90th percentile.)

How did they do it?

One way was by working with staff from radiology, laboratory, registration and administration to expand capacity and improve flow. By communicating with other departments the ED was able to identify extra space adjacent to their ED to expand into, and then brought on additional physicians and nurses.

They also streamlined the registration process by taking basic information during triage, and pressed hospital leadership to start discharging in-patients in the morning, as opposed to the afternoon. Additionally, housekeeping was requested to clean rooms in a timelier manner.  

3. Keep it simple.

In 2001, Annie T. Sadosty, MD, an attending physician in the department of emergency medicine at Mayo Clinic, and assistant professor at Mayo Medical School, studied the reasons patients leave an ED without being seen. During her research, Sadosty and her colleagues were also able to glean what would cause patients to wait. The results were interesting.

She found that patients would be more likely to wait if they were offered immediate treatment for minor ailments, such as Tylenol for a headache, or ice packs and temporary bandages for injuries. Sadosty also found that by simplyannouncing wait times, patients said they would be more willing to stick around. Providing entertainment for children — think coloring books and toys — would also help, patients told Sadosty.

As you can see, the factors that lead to high LWBS rates are just as varied as the solutions. If you find that your patients are leaving without being seen, 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 lower your LWBS rate. Contact us today at or 651-260-9918. For more information on the services we offer, visit our website.


Renee Y. Hsia, MD, MSc, Steven M. Asch, MD, MPH, Robert E. Weiss, PhD, David Zingmond, MD, PhD, Li-Jung Liang, PhD, Weijuan Han, MS, Heather McCreath, PhD, and Benjamin C. Sun, MD, MPP: “Hospital Determinants of Emergency Department Left Without Being Seen Rates”

GMH ED Staff, Sylwia Wright, RN, MSN, Mark Cichon, DO: “Decreasing Left Without Being Seen”

Urgent Matters: “Reducing the Left Without Being Seen (LWBS) Rate and Throughput Time Miami Children’s Hospital”

Arendt KW, Sadosty AT, Weaver AL, Brent CR, Boie ET: “The left-without-being-seen patients: what would keep them from leaving?”

AHC Media: “Want to drastically cut LWBS numbers? Try ice packs and adding a fast track”

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

The Importance of a Strong Discharge Checklist


The moment a patient is discharged from the emergency department (ED) should be a moment marked with confidence for both the patient and ED staff. Each party should be satisfied with the care provided and that the chance of a return visit to the ED in the near future are low.

A visit to the ED is typically stressful for a patient and their families. From the time they walk in your door until they get to discharge can be an arduous experience. But by engaging patients with effective communication throughout thier experience and especially before the leave they’ll be empowered with the necessary knowledge to ultimately take control of their care.  

One important tool for effective communication every ED should utilize is the discharge checklist.

According to the Robert Wood Johnson Foundation, patients should have a solid understanding of these six things prior to discharge:

  1. Their overall care plan;
  2. Where they will be going after discharge;
  3. If transferred, who to contact if a problem arises;
  4. Medication instructions along with potential side effects;
  5. What symptoms to be on the lookout for;
  6. And any necessary follow-up appointments.

This is a lot of information for a person or family to absorb, especially when they find themselves in the ED. A strong discharge checklist will provide this essential information in a way that’s easy for patients and caregivers to understand as the ED staff person reviews it with them and once they take it home. Just as important, a strong discharge checklist will instill confidence among the ED staff that all pertinent information has been shared with the patient.

So, what does a strong discharge checklist look like?

The best discharge checklists are educational in nature and address social and medical risk factors that could result in a return visit to the ED. If the patient is homeless, a list of area agencies that offer housing assistance should be included. The same goes for patients who have issues involving substance abuse.

Strong discharge checklists should also be simple in form and created with the demographics of the community the ED serves in mind. If there is a high population of Spanish-language speakers in the community, it’s best to have the checklist available in Spanish as well.

Discharge checklists of course can’t be tailored to every individual patient, but a strong checklist will cover the necessary bases to ensure discharge is successful for the vast majority of patients.

The Robert Wood Johnson Foundation offers a good model for what a strong discharge checklist should look like, as does The important element these two checklists share is that they both empower patients and caregivers with points of action.

For example:

I understand what symptoms I need to watch out for and whom to call should I notice them.

This is a good example of how proper wording places the primary responsibility of care on the patient with ED staff acting as a guide. Nurses aren’t checking off the box when they relay necessary information to patients. Instead, patients and caregivers are checking the box off when they have a firm grasp on the information that’s been presented to them.

The discharge process for every ED is different, but the one tool each should be utilizing is a strong discharge checklist. While there’s not a “one-size-fits-all” checklist out there, Donovan and Partners is available to assess your ED and help you develop a tailored discharge checklist to lower return rates and improve the discharge process.  Contact us today at or 651-260-9918.

Robert Wood Johnson Foundation: “Care About Your Care Discharge Checklist & Care Transition Plan.” "Your Discharge Planning Checklist."

American College of Emergency Physicians: “Improving the ED Discharge Process.”

What Is The Emergency Medical Treatment and Active Labor Act (EMTALA)? Why Is It Important?


EMTALA is the federal law that ensures people can access emergency care, whether or not they can pay. When someone goes to the emergency room with a medical emergency they must be seen, receive a medical screening exam and be stabilized if the hospital has the ability to do so. Generally, people interpret it to mean: a hospital can’t turn a patient away without the benefit of a medical screening examination.

Of course nothing is simple and EMTALA carries its own controversy along with it. People tend to fall into one of two camps: Either EMTALA is one of the great things about living in America -- it ensures that people who need emergency care receive it. It’s a safety net.

Or, others believe that EMTALA drives up the cost of healthcare and adds to financial difficulties hospitals experience. That’s because when EMTALA was written into law, funding was not written into the federal budget to pay for it. 

How does EMTALA affect to emergency departments?

Some pinpoint EMTALA as a cause for emergency department overcrowding. Politics and opinions aside, as an emergency department, you must be ready to evaluate and stabilize basically any and all who come your way. To do that you need to make sure the following are in place and buttoned up:

  • intake and triage processes
  • patient flow protocols
  • staffing and scheduling procedures

Failing to provide medical screening examination and stabilize patients can cost you in penalties and lawsuits.

Why does EMTALA matter to doctors and hospital administrators?

You need to know what the law requires. When patients show up at your door, every effort must be made to complete a medical screening exam and initially stabilize the patient within the abilities of your hospital. Know that if your hospital cannot fully stabilize a patient, you must transfer them to another facility with the capabilities to do so. You must also transfer the patient, if they request to be transferred.

The nuances of EMTALA are not always easy and it can get tricky. How can you be sure you’re complying with EMTALA? You may wonder what counts as an “emergency medical condition”? What should your medical examinations involve to make sure you are providing a screening that will comply as an “emergency medical screening” under the law?

For these questions, it is best to go by the book. Luckily, the Center for Medicaid and Medicare Services have these online resources so you can look up the law.

You need to know what counts as an emergency. For a brief explanation of what counts as an emergency condition, the American College of Emergency Physicians summarizes it this way:

“An emergency medical condition is defined as ‘a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.’”

You need to be prepared to cover the costs. And since seeing patients who seek care but cannot pay does cost money, physicians and hospitals are left absorbing that cost. According to the American College of Emergency Physicians: “Emergency physicians provide the most charity care of all physicians (AMA 2003).”

 Because of this, the group advocates for ways to get emergency doctors compensated for EMTALA patients and federal guidance on how to comply with the law.

 The cost of treating patients who cannot pay is passed down to hospitals and may ultimately be passed down to other patients at the hospital.

Who gets fined for EMTALA violations?

Physicians can be fined up to $50,000 per violation and lose their ability to receive Medicare reimbursements. Depending on its size, the hospital can also be fined up to $50,000, or more, depending on the number of violations. A hospital can also lose its Medicare funding, a significant source of revenue in most hospitals. A hospital can also sue another hospital that passes along a patient that isn’t stabilized.

How can Donovan and Partners help with challenges associated with EMTALA? 

While Donovan and Partners is not an EMTALA compliance specialist, we can help you take a look at your emergency department’s protocols and procedures to make sure you are capable of handling some of the situations that EMTALA can create and ensure that everyone gets quality care. We can help you examine and improve your:

  • emergency department’s intake and triage process
  • patient flow protocols
  • staffing and scheduling procedures

We’ll help you implement best practices so you’re prepared and in good position to handle any strains EMTALA may cause. In addition, we can also help with CMS response and action plan development in the event you are cited. Contact us today at or 651-260-9918.


Centers for Medicare and Medicaid Services: “Emergency Medical Treatment & Labor Act (EMTALA)”

American College of Emergency Physicians: “EMTALA”

How to Decode and Fix Low Patient Satisfaction Scores

Patients have an uncanny ability to pick up on underlying areas that need improvement in your hospital. Do you know how to translate what they’re saying? Learning how to interpret patient satisfaction results is becoming even more crucial because of upcoming changes to Centers for Medicare & Medicaid Services (CMS) scoring.

How to Decode and Fix Low Patient Satisfaction Scores.jpg

Starting next year, your hospital’s overall reimbursement score will be impacted by how well your emergency department does on patient satisfaction surveys. It could cost your hospital a percent of your Medicaid reimbursement.

Here is how to translate some patient satisfaction results into changes for good.

Low score on: Attentiveness of nursing staff

Take a look at: Your staffing ratios and scheduling and rounding procedures

Nurses that don’t have time to spend with patients and satisfaction scores reflect that. Patients report less empathetic nurses when the nurses are harried and pressed for time.

In California, safe staffing laws have stated the appropriate staffing ratio in emergency departments is four patients to every nurse. The closer you are to that ideal the more time nurses have to talk with patients and provide quality care. Not only do patient satisfaction scores rise but outcomes can too.

If you feel you can’t afford new hires, take a look at how you’re doing scheduling. Maybe you can rebalance how staffed up your emergency department is so you’re making the most of the staff you do have and are balancing your staff to workload ratio appropriately.

Another way to boost scores in this arena: take a look at rounding. Are patients being checked on every hour by staff? When you provide scripting for allied health professionals when they complete rounds it makes it easier for the staff and ensures that patients are being listened to and their basic needs are being cared for.

Low score on: Delays in care

Take a look at: Operational efficiencies

How is patient triage upon arrival? Does your staff have processes in place to rapidly assess whether a patient is suffering from a heart attack or sore throat and get them the proper care? Develop processes to provide the right service with the right provider at the right cost. This approach requires developing clear procedures for routing patients efficiently and effectively to the appropriate treatment area and for diagnostics, e.g. x-rays.  Putting specific processes in place creates efficiencies and cuts down on the possibility of a patient languishing in one area and long throughput times.

For more insights into what your patient satisfaction scores are trying to tell you, reach out to me. I am happy to help your emergency department with an assessment that uncovers opportunities for improvement and outlines recommended actions.