Leon L. Haley

Transforming Hospital Emergency Department Workflow and Patient Care

When we encounter an unexpected critical health problem, a hospitals emergency department ED becomes our vital medical resource. Improving an EDs timeliness of care, quality of care, and operational efficiency while reducing avoidable readmissions, is fraught with difficulties, which arise from complexity and uncertainty. In this paper, we describe an ED decision support system that couples machine learning, simulation, and optimization to address these improvement goals. The system allows healthcare administrators to globally optimize workflow, taking into account the uncertainties of incoming patient injuries and diseases and their associated care, thereby significantly reducing patient length of stay. This is achieved without changing physical layout, focusing instead on process consolidation, operations tracking, and staffing. First implemented at Grady Memorial Hospital in Atlanta, Georgia, the system helped reduce length of stay at Grady by roughly 33 percent. By repurposing existing resources, the hospital established a clinical decision unit that resulted in a 28 percent reduction in ED readmissions. Insights gained from the implementation also led to an investment in a walk-in center that eliminated more than 32 percent of the nonurgent-care cases from the ED. As a result of these improvements, the hospital enhanced its financial standing and achieved its target goal of an average ED length of stay of close to seven hours. ED and trauma efficiencies improved throughput by over 16 percent and reduced the number of patients who left without being seen by more than 30 percent. The annual revenue realized plus savings generated are approximately

When Patients Are Impatient: The Communication Strategies Utilized by Emergency Department Employees to Manage Patients Frustrated by Wait Times

190 million, a large amount relative to the hospitals

Clinical operations in academic emergency medicine.

1.5 billion annual economic impact. The underlying model, which we generalized, has been tested and implemented successfully at 10 other EDs and in other hospital units. The system offers significant advantages in that it permits a comprehensive analysis of the entire patient flow from registration to discharge, enables a decision maker to understand the complexities and interdependencies of individual steps in the process sequence, and ultimately allows the users to perform system optimization.

Benefit of a Tiered-Trauma Activation System to Triage Dead-on-Arrival Patients

Studies have documented the frustrations patients experience during long wait times in emergency departments (EDs), but considerably less research has sought to understand ED staff responses to these frustrations. In-depth interviews were conducted with 18 ED social workers, patient navigators, and medical staff members at a large urban hospital regarding their experiences and interpersonal strategies for dealing with frustrated patients. Staff indicated that patients often attribute delays to neglect and do not understand why their health problem is not prioritized. They voiced several strategies for addressing wait time frustrations, including expressing empathy for patients, making patients feel occupied and wait times seem more productive, and educating patients about when health issues should be treated through primary care. All staff members recognized the need for engaging in empathic communication with frustrated patients, but social workers and patient navigators were able to dedicate more time to these types of interactions.

Disparities in Emergency Department Health Care: Systems and Administration

The operations of an emergency department are increasingly being recognized as vital to the provision of safe, efficient, quality care. The numerous and highly variable processes that characterize our system must be closely examined and investigated to identify those which are effective and those which are not. Original research in this field should be promoted and embraced by our society for both our patients and our profession. Effective operational processes should ultimately be seen as those which preserve and enhance the patient-physician relationship.

Kiosk versus In-person Screening for Alcohol and Drug Use in the Emergency Department: Patient Preferences and Disclosure

Introduction Although national guidelines have been published for the management of critically injured traumatic cardiopulmonary arrest (TCPA) patients, many hospital systems have not implemented in-hospital triage guidelines. The objective of this study was to determine if hospital resources could be preserved by implementation of an in-hospital tiered triage system for patients in TCPA with prolonged resuscitation who would likely be declared dead on arrival (DOA). Method We conducted a retrospective analysis of 4,618 severely injured patients, admitted to our Level I trauma center from December 2000 to December 2008 for evaluation. All of the identified patients had sustained life-threatening penetrating and blunt injuries with pre-hospital TCPA. Patients who received cardiopulmonary resuscitation (CPR) for 10 minutes were assessed for survival rate, neurologic outcome, and charge-for-activation (COA) for our hospital trauma system. Results We evaluated 4,618 charts, which consisted of patients seen by the MSM trauma service from December 2001 through December 2008. We identified 140 patients with severe, life-threatening traumatic injuries, who sustained pre-hospital TCPA requiring prolonged CPR in the field and were brought to the emergency department (ED). Group I was comprised of 108 patients sustaining TCPA (53 blunt, 55 penetrating), who died after receiving < 45 minutes of ACLS after arrival. Group II, which consisted of 32 patients (25 blunt, 7 penetrating), had resuscitative efforts in the ED lasting > 45 minutes, but all ultimately died prior to discharge. Estimated hospital charge-for-activation for Group I was approximately

Reasons for Using the Emergency Department: Results of the EMPATH Study

540,000, based on standard charges of

Racial and ethnic disparities in the emergency department: a public health perspective.

5000 per full-scale trauma system activation (TSA). Conclusion Full-scale trauma system activation for patients sustaining greater than 10 minutes of prehospital TCPA in the field is futile and economically depleting.

The Emergency Department as a prevention site: A demographic analysis of substance use among ED patients

Disparities are likely to present both in the emergency department and within the larger health care system; however, disparities must be recognized to be addressed. This article summarizes the proceedings from the AEM Consensus Conference 2003: Disparities in Emergency Health Care. The goals of the conference were to examine the presence, causes, and outcomes related to disparities of health care as they occur in emergency departments, and determine the degree to which external forces have an impact on our patients. Participants were asked to describe the means of defining, assessing, measuring, and investigating disparities that may occur in emergency care. The committee members who wrote this report were asked to examine the influence of health care systems and administration on disparities in health care, using the following series of questions to frame the discussion. 1) Are all disparities bad? 2) Are only the vulnerable served inadequately by our current health care system? 3) Are what appear to be inequities really systems incompetence? 4) We assume there should be no inequality in health care: does society also assume this? 5) What would be the systems costs of equality in health care?

Hospital emergency departments: where the doctor is always "in".

Introduction Annually eight million emergency department (ED) visits are attributable to alcohol use. Screening ED patients for at-risk alcohol and substance use is an integral component of screening, brief intervention, and referral to treatment programs, shown to be effective at reducing substance use. The objective is to evaluate ED patients’ acceptance of and willingness to disclose alcohol/substance use via a computer kiosk versus an in-person interview. Methods This was a cross-sectional, survey-based study. Eligible participants included those who presented to walk-in triage, were English-speaking, ≥18 years, were clinically stable and able to consent. Patients had the opportunity to access the kiosk in the ED waiting room, and were approached for an in-person survey by a research assistant (9am–5pm weekdays). Both surveys used validated assessment tools to assess drug and alcohol use. Disclosure statistics and preferences were calculated using chi-square tests and McNemar’s test. Results A total of 1,207 patients were screened: 229 in person only, 824 by kiosk, and 154 by both in person and kiosk. Single-modality participants were more likely to disclose hazardous drinking (p=0.003) and high-risk drug use (OR=22.3 [12.3–42.2]; p<0.0001) via kiosk. Participants who had participated in screening via both modalities were more likely to reveal high-risk drug use on the kiosk (p=0.003). When asked about screening preferences, 73.6% reported a preference for an in-person survey, which patients rated higher on privacy and comfort. Conclusion ED patients were significantly more likely to disclose at-risk alcohol and substance use to a computer kiosk than an interviewer. Paradoxically patients stated a preference for in-person screening, despite reduced disclosure to a human screener.