The Emergency Department - Prepared for the unexpected

February 18, 2010

Ann is a mystery. Her family called paramedics after Ann (not her real name) appeared to faint at home. In theambulance, the elderly woman complained of abdominal pain. As soon as Ann arrives in the Hospital of Central Connecticut (HCC) Emergency Department, Marilyn Robidoux, R.N., B.S.N., begins working to solve the mystery. “Hi, Ann. Do you know where you are? You’re at the hospital,” Robidoux says. “Does
anything hurt? Are you nauseous?” Ann mumbles unintelligibly. Robidoux takes her vital signs and connects her to a monitor. It’s Robidoux’s second patient since she started at 7 a.m. at the hospital’s New Britain General campus.

The first had back pain, was examined and sent home with Motrin. Throughout Robidoux’s 12-hour shift, many patients will come and go within an hour or two. Others, like Ann, will be here awhile. Emergency physician Michelle McDade, M.D., has given Ann a preliminary exam, but fainting can have many causes and tests are needed. Nursing Technician Al Glass draws some of Ann’s blood, and a chest X-ray and CT scans of her abdomen and head are ordered. Robidoux enjoys this detective work. “I love finding out what’s wrong with people and fixing it,” she says.

No time to wait

By 7:45 a.m. the 45-bed New Britain General campus ED is about half-full, but that won’t last. Eight patients have arrived in the past 11 minutes. Still, Robidoux says, it’s somewhat ... less active than usual. “We never say the words ‘quiet’ or ‘slow,’” she warns. “It jinxes us.” This morning is an anomaly. Lately the hospital’s New Britain General and Bradley Memorial campus EDs have seen record numbers.

One Monday in November, the New Britain ED treated 362 patients; normally it treats 245 on average daily. Though not all are coming with flu-like symptoms, H1N1 influenza is partly to blame. But even before H1N1 hit, the HCC Emergency Department was one of the busiest in the state, with more than 100,000 visits in fiscal year 2009 for both campuses combined. Despite this volume, the ED has some of the shortest wait times nationwide.

Average time from arrival to treatment room at New Britain General is less than 15 minutes; less than six minutes at Bradley Memorial. Ninety to 95 percent of patients are seen by a physician or physician assistant within 60 minutes. “Those kinds of wait times are virtually unheard of in this
field,” says Jeffrey Finkelstein, M.D., HCC’s chief of Emergency Medicine. Monitors in each campus ED lobby display wait times, which are updated every three minutes. Wait times are also available on HCC’s Web site, www.thocc.org, and via an iPhone app. One reason for shorter wait times is a $6.5 million expansion and renovation at the New Britain General campus that added 10,000 square feet and 11 beds.

The project, completed in 2008, also created private rooms (vs. beds separated by curtains), updated equipment and included other improvements. The Bradley Memorial campus ED was also recently renovated and a new Fast Track area opened to treat less-urgent illnesses or conditions. New Britain General also has a Fast Track.But the main reason for shorter wait times is a comprehensive effort to improve customer service that began six years ago. That effort has included staff education in efficiency and customer service and better patient tracking to ensure people are seen as quickly as possible. The ED also implemented a comprehensive information system that continuously monitors capacity and waits; improves safety; offers real-time decision support; and makes it easier for clinicians to document and review vast amounts of data. 

“We’re dedicated to providing outstanding care with outstanding service,” Finkelstein says. “There are very few places that do what we do, 24/7.” Patients have noticed. “This was excellent,” says John Taylor of Bloomfield, who’s being discharged after McDade splinted his broken wrist. “I think I had to wait maybe five minutes to see the doctor this morning.” McDade diagnosed Taylor’s wrist break just a short time earlier, after checking an X-ray sent electronically to the ED from Radiology. Virtually all information that used to be hand-written or printed out is now handled electronically in the ED, and technology has
played an important role in enhancing care and service.

In 2005, the ED launched EmpowER, a comprehensive information system that makes patients’ medical histories, test results, treatment details and other data instantly accessible to ED care providers. Data can also be securely shared between both campuses and automatically sent to patients’ primary care physicians and other healthcare providers when required. ED staff document everything in EmpowER — observations, tests ordered, treatments provided and anything else germane to a patient’s care. “In the ED, we walk like crazy and we document like crazy,” McDade says. They also multi-task like
crazy. During a nine-hour shift, McDade will treat an average of 21 patients, though on a recent busy day, she saw 34. This morning, in the space of 10 minutes, she ricochets between Ann, a patient with an eye injury, another with suspected heart trouble, another with wrist pain and a volatile patient with symptoms of paranoia. “In this field, the ability to multi-task is as important as your medical knowledge,” McDade says.

A dangerous clue

Robidoux is on the computer when Ann’s heart rate plummets from the upper 50s to 24 beats per minute. Her bedside monitor wails. Glass, the nursing technician, appears out of nowhere and in one fluid motion, he and Robidoux rush a red cart of emergency supplies to Ann’s room. Robidoux grabs some “pacer pads” and places them on Ann’s chest. The pads are connected to a device that allows Robidoux to stimulate Ann’s heart and get it pumping faster. It works. The episode is a dangerous but important clue to Ann’s illness. McDade suspects sick sinus syndrome, the term for a group of heart-rhythm disorders. A cardiologist is called to examine Ann and talk with her family about further tests and treatment options.

Telling not quite right from wrong

Richard Steinmark, M.D., has his own mystery patient. A man was brought to the ED at HCC’s Bradley Memorial campus in Southington late this morning because he “didn’t look quite right.” Indeed, the patient is not quite right: His blood pressure, blood sugar and heart rate are low, and he’s confused. Steinmark is awaiting more test results, but acknowledges that in patients with multiple health issues it can be hard to pin down a main cause for their symptoms. “Most of the time if people come in with an acute problem
it’s because of something that happened that day,” Steinmark says. “But there are times when we don’t know exactly what’s wrong and all we can do is rule out anything life-threatening. It can be frustrating, because I like being able to fix things and help people.” For now, the patient will receive oxygen and fluids, have multiple tests and constant monitoring.

As he awaits admission to the hospital’s Intensive Care Unit, Bradley’s 10-bed ED begins filling up. Though smaller than New Britain General, it’s also busy — with 18,000 visits in fiscal year 2009. Adam Scheck accounts for two of those visits. A couple months ago he was chopping wood and a finger got in the way. He came to the ED this morning after falling down some stairs outside his house. “Fortunately, my neighbor was outside,” Scheck says. “He said, ‘Man! I heard your head hit!’” Physician Assistant Jennifer McDonnell checks an X-ray of Scheck’s shoulder and a CT scan of his head. Nothing is broken or
seriously injured, so he can go home with pain medication.

As he’s leaving, Jonathan Leveille arrives with abdominal pain. Initially, his complaint seems minor, so he’s escorted to the Fast Track area. But after an exam, McDonnell decides to move him to the main ED and orders an abdominal ultrasound and blood tests. “That’s the advantage of Fast Track,” says Rene Hipona, M.D., assistant chief of Emergency Medicine at the Bradley Memorial campus. “Patients
requiring less urgent care can receive it quickly and go home, but if we think a patient needs more tests and closer examination we can bring them to the main ED.”

Another patient also has abdominal pain. Steinmark diagnoses an infection and gives her antibiotics, but recommends she be admitted to the hospital because of an elevated heart rate and history of heart trouble. There are other concerns. Mary Ann Pinkerton, R.N., learns the patient hasn’t been eating or drinking at home. Because she lives alone, Pinkerton will ask a hospital social worker to work with the woman and her family and determine if she needs assistance at home. In the relatively short time they spend with their patients, ED staff might get only a brief glimpse into their lives. But the details in these snapshots are important. “We have to look at the physical issues, the psychosocial issues, the family dynamics — all the different aspects of our patients’ lives,” Pinkerton says.

We never say no

Robidoux is worried about her patient in room 32. He’s a frequent ED patient — 28 visits in 2009 — and has a history of alcoholism and substance abuse. Still, he seems more out-of-it than Robidoux has seen him in the past. “We get to know these people and we know when they’re off,”
she says. Patients with substance abuse problems are common in the ED; some come in more than once a day. Often, all ED staff can do is run tests to see if other medical
issues are causing their symptoms. If there are no serious
problems, staff must wait until patients sober up enough to be discharged. Hospital staff will recommend treatment programs, but it’s up to the patient to follow through. The ED also treats many patients with psychiatric illness, usually in the ED Observation — “Obs” — Area. McDade’s frenetic pace has temporarily slowed as she and another nurse sit and talk quietly with a patient in Obs who was recently diagnosed with a serious illness and is suicidal. The patient will be admitted to the hospital’s psychiatric unit. Another of McDade’s patients will also be admitted, to a medical
unit. When she came to the ED the woman didn’t know the
discomfort she was experiencing was actually a mild heart attack. She was reluctant to come to the hospital because she has no health insurance. She’s far from alone. Nationwide, emergency department use has skyrocketed
in recent years as people without insurance seek care. Unlike McDade’s patient, many are not true emergencies,
but have nowhere else to go. “People know they can come to
the ED,” says Sean Raimo, R.N., a Bradley ED nurse. “If someone needs help, we never say no.” This creates a conundrum for those in emergency medicine, because their
mission is to care for anyone, regardless of the person’s ability to pay. Yet that care is far from free. With daily New Britain ED staffing at around seven physicians, 16 nurses,
five nursing technicians and other staff, along with equipment, utilities and supplies costs, “it probably costs
us $10,000 an hour to stay open,” Finkelstein says.

Only the best

Some of the ED staff wear T-shirts that say: “Emergency Department staff … Prepared for the unexpected.”
It sounds like an oxymoron, but here, it isn’t. The best people in emergency medicine have the skills and
expertise to treat just about anything, the instincts to know when something’s not as it seems and the mental
and physical reflexes to act in a nanosecond. “We hire only the best staff, the right people,” says Robert Flade, R.N.,
M.S., HCC’s director of emergency nursing. “They know they make a positive difference in their patients’ lives.”
That’s why Glass left a job with the U.S. Postal Service to become a nursing technician nine years ago. “My brother, Dave, was killed by a drunk driver in 1998,” says Glass.
“After that I felt like I wanted to do something to help others. I do this for my brother, and I get a lot of satisfaction
from my work.” Robidoux joined the ED nine years ago, and wouldn’t work anywhere else.
“You see so many different patients, and things change constantly,” she says. “It can be exhausting, but I love coming to work every day.”