Lyndon B. Johnson General Hospital, a county-funded, safety net institution in economically disadvantaged northeast Houston, is the sole hospital to provide inpatient, obstetric, and emergency care for nearly 25% of the city’s land area. Although it remained open for operations during Hurricane Harvey in late August 2017, the storm caused significant moisture damage to its infrastructure, necessitating the closure of more than half of its 200 inpatient beds for several months after the storm.
The hospital’s emergency department (ED) continued to provide effective emergency care to the community — many of whose members had substantially increased need for medical care after the hurricane. To do that, the ED, which already operated with the resource constraints of crowding (more patients than treatment spaces) and boarding (insufficient inpatient beds, which requires patients to stay in the ED until beds are available), had to undergo sweeping changes almost overnight.
Six months later, largely as a result of this revamping, the ED is now more efficient and safer than ever before — despite a sustained 7.5% surge in volume after Hurricane Harvey struck. Below, we detail some of the major interventions that allowed us to achieve this feat without increasing costs.
Condense the emergency department. After closing more than half of the hospital’s inpatient beds, it seemed intuitive that the most significant bottleneck to patient flow would be a paucity of those beds. But we realized that because of that action, we were greatly underusing our inpatient clinician and nurse colleagues who were ready and able to see patients wherever possible. As a result, we converted one of our ED treatment areas with 16 private rooms to an inpatient unit staffed by inpatient nurses and physicians. This action condensed the ED’s total square footage by 30%. We simultaneously repurposed previously unused spaces —hallway spaces, chairs, recliners, and even parts of the waiting room —into active treatment areas.
Keep patients vertical. With the reduction in the number of private treatment spaces in the ED, we identified that “keeping patients vertical” was vital. As is true of many EDs throughout the nation, we knew that a subset of patients who present to the Lyndon B. Johnson General Hospital’s ED do not require a stretcher or private room (and consequently need not be “horizontal”) to complete their care. For our ED, this subset of patients was estimated to be as high as 40% to 50% of the ED volume on certain days.
We proposed that patients who did not require a private room or stretcher remain seated in a chair during their ED evaluation and treatment. This allowed us to reserve private rooms and stretchers for patients who needed them most and to fit more patients on chairs into the same space compared to horizontal patients lying on stretchers.
The ED was reconfigured to allow us to care for more sitting patients, and protocols were established to rapidly identify patients who could remain vertical throughout their ED stay. As a result, the vertical patients were seen by a provider quickly and thereby processed through the system more expeditiously than horizontal patients, allowing the ED as a whole to see and treat a greater proportion of patients in shorter times.
Parallel processing is key. Historically, patients had waited until a bed was available in the ED, at which point they would see a provider and nurse who would assess and treat them while they remained in that location; patients were left in the same treatment space from arrival until their care was completed. Post-Harvey, it was recognized that many patients did not need to remain in their assigned treatment spaces and instead could be moved to a separate, low-acuity part of the ED to await the results of their testing and consultations. We termed this area “Results Waiting.”
This allowed the next patient to occupy the treatment spaces vacated by patients moved to Results Waiting. We also had providers order necessary testing for those patients in the traditional waiting room who had not yet been fully evaluated. These changes cumulatively decreased our door-to-provider time, our door-to-disposition time, and our percentage of patients who left the ED without being seen by a provider, despite the 7.5% increase in ED volume and 50% reduction in inpatient capacity from Hurricane Harvey damages.
Ask for help. Lyndon B. Johnson General Hospital worked hard to care for all of its patients. However, we realized that for a hospital that saw 81,000 patients in 2016, the existing 200 inpatient beds were often not enough to care for all of the patients presenting to the ED. Although we frequently asked our own hospital’s inpatient teams to help care for admitted patients when the ED became busy, we rarely asked other hospitals for help when we saw spikes in the number of patients who required admission.
Faced with increasing volumes, in part driven by the permanent closure of another hospital in our county after Harvey, we realized the deleterious effects of boarding too many admitted patients in the ED. These patients were better served in an inpatient bed, even if that bed was at a different hospital. We developed a process for transferring them to other Houston-area hospitals that had the capacity to care for them more rapidly than we could that we could. By doing this, we were able to drive ED boarding hours, which is the time that ED patients spend waiting for an inpatient bed, down to levels not seen in the last five years.
The changes implemented during Hurricane Harvey have been sustained. Lyndon B. Johnson General Hospital’s ED boasts a volume of 7,430 patients per month, making it the busiest adult emergency department in Houston. The number of patients who leave without being seen decreased by 29% in the quarter after Harvey. The average time patients wait until they see their first provider decreased by 22%. Boarding hours dropped by 52%. Serious safety events have declined, suggesting that the changes have driven safer, not just more efficient, care. Morale among ED personnel is higher than ever before.
All of this happened in spite of a 7.5% increase in overall patient volume and a more than 200% increase in the highest acuity cases.
An often-referenced adage states: “Never let a good crisis go to waste.” At the Lyndon B. Johnson Hospital’s ED, we believe we took advantage of unique opportunities for rapid change imposed upon us by Hurricane Harvey and made improvements that have produced sustained benefits for our patients and our hospital.