Palomar Medical Center 'Rapid medical evaluation' designed to fast-track patients

By: ANDREA MOSS - Staff Writer | Saturday, October 13, 2007 9:08 PM PDT ∞

ESCONDIDO -- Just about everyone has heard the stories, and some have experienced them firsthand: Go to Palomar Medical Center's emergency room, and you're likely to sit there for hours.

Dr. Jaime Rivas, medical director of the emergency department at the downtown Escondido hospital, as well as the Pomerado Hospital in Poway, said last week that tales like that keep him up at night.

"My worst thing as the director of the department is to be at a function with my kids and have a parent or someone say, 'I waited a long time in your emergency department,' " Rivas said. "My dream is to have people just be able to say, 'Wow, I was seen in an efficient, timely fashion and treated with compassion.' "

While there will always be times when patients endure long waits for a variety of reasons, he said, a "rapid medical evaluation" program that the hospital launched in August has helped the facility reduce the average waiting times in its emergency room to their lowest point in 10 months.

Reports provided by Palomar Pomerado Health, which operates both hospitals, show patients waited an average of 39 minutes to see a doctor in September.

That "door to doc" time beat the average for a group of nearly 70 hospitals around the state by four minutes, the reports show. The average -- which takes into account the wait times for all patients using the emergency room, regardless of whether they arrive by ambulance or walk in -- also is nearly half what it was in March, when patients waited an average of 76 minutes, according to the reports.

Palomar's achievement puts it in the middle of a list of waiting times for North County hospitals, whose average waiting times ranged from 24 to 58 minutes.

Rivas said shorter wait times do not mean patients are getting better care, because those coming into the emergency room with high-priority medical needs get bumped to the front for treatment. Studies have shown, however, that people believe they are getting a higher-level of care if they are seen faster, the physician said.

"It's a perception issue," he said.

Times tracked, compared
Designed to fast-track patients through the emergency room, the new program put a team of doctors, nurses, nurse-practioners and physicians' assistants in a special area near the front of the department, Rivas said.

There, they get patients' medical histories, do preliminary exams and order diagnostic tests for people who need them, the physician said. The change eliminates time that is often lost while patients wait for emergency room beds to open up, then wait again for the physician who will treat them to order the necessary tests after examining them, he said.

Predicting that Palomar's waiting times will continue to go down, Rivas said he was pleased with the program's initial results.

"That drop (in numbers) makes me sleep at night," he said.

Hospitals are not required to report their emergency room waiting times, though health care administrators inside and out of Palomar Pomerado said that may soon change. Many hospitals share their times with each other, out of a shared desire to find ways to reduce long waiting times, said Dr. Jim LaBelle, director of emergency services and medical director of quality for Scripps Memorial Hospital Encinitas.

"There is a lot of communication between the ERs as to how to deal with this crisis," he said. "And it is a community health care crisis."

His hospital, Tri-City Medical Center in Oceanside, and Fallbrook Hospital joined Palomar Pomerado Health in sharing information about their waiting times for this story. The numbers show that emergency room patients at Tri-City had the shortest average wait -- 24 minutes --- to see a doctor last month.

That compared with 38 minutes at Poway's Pomerado Hospital also runs; 42 minutes at Fallbrook Hospital; and 58 minutes at Scripps Memorial Hospital Encinitas.

All five hospitals' times fluctuated from month to month over the last year, making it difficult to identify any one facility as clearly being better at getting patients in and out of its emergency room. A 12-month chart of Palomar's waiting times shows a peak of 76 minutes in March, then zigzagged between 59 and 71 minutes for several months before showing significant and consecutive drops in August and September. The other hospitals' average waiting times showed similar ups and downs.

Extended waits still occur
Average turnaround time, or the amount of time between patients' arrival and departure times, is also tracked and compared. Palomar's average turnaround for patients who were not admitted or were transferred to other facilities was reported at three hours and three minutes in September.

Although that was down from three hours and 16 minutes in July, it was still 26 minutes longer than the average for the other hospitals.

Scripps Encinitas had the fastest turnaround for all North County hospitals in September, reporting an average of two hours and 47 minutes for patients who were not admitted or were transferred to other facilities.

Other hospitals' average turnaround times were three hours and one minute at Pomerado, three hours and three minutes at Fallbrook Hospital and Palomar Medical Center, and three hours and 46 minutes at Tri-City.

Hospital administrators said a multitude of factors affect waiting times. Variables cited include patient volumes, types of illnesses and injuries treated on a given day, number of beds available in both an emergency room and the hospital that houses it, the need for diagnostic tests, and the speed with which on-site laboratories can produce test results and diagnostic scans.

"So many things have to work for it to come out right," Rivas said, adding that a glitch in any one area can cause an emergency room to bog down.

Because the reported times are averages, they also do not reflect instances in which patients spend hours and hours in the emergency room's waiting area or an exam room. Acknowledging that sometimes happens, Rivas said waits typically get drawn out when doctors need multiple diagnostic tests for a patient, they are treated during a period of great patient volume, or they are waiting for a bed to open up before they can be admitted.

The physician also said the number of people in that category represent a small fraction of the total number coming through the emergency room in a given month.

"In August, we saw 5,000 patients," Rivas said. "Say 50 of those 5,000 had extended waits. Obviously, my goal would be to have none of that. But 50 of 5,000 is less than 1 percent."

He said Palomar's current goal is to get patients in and out in three hours or less. Once that mark is hit, the physician said, the goal will probably be set lower.

Speeding up the flow
Rivas and other North County hospital officials said managing an emergency room efficiently has proved to be one of the best ways to keep the flow of patients moving. Many hospitals are adopting the strategy of putting more people up front to triage patients for that reason, the administrators said.

Requiring emergency room doctors to write up orders and prescriptions for patients as soon as they finish examining them, establishing turnaround time goals for in-house labs, and installing X-ray machines close to the emergency department to reduce the time spent moving patients around are some of the other steps local hospital administrators are being taken to improve efficiency, administrators said.

They agreed bed shortages are a harder problem to fix. Rivas said people in the waiting room for Palomar's emergency room often don't realize they are sitting there because patients in the department's treatment rooms need to be admitted to the hospital but are waiting for one of its 328 beds to open up or be readied.

LaBelle said the problem is one most hospitals experience from time to time. Scripps Encinitas is preparing to double the number of beds in its emergency room from 12 to 24, as a partial solution, he said.

LeBelle and Kim Colonnelli, administrator of emergency, trauma and forensic sciences administrator at Palomar, said it faces unique challenges on that front because the 328-bed hospital's central location in inland North County and its status as the region's trauma center means Palomar has an unusually high patient-bed ratio. Patient volume reports show 57,090 people were treated in the hospital's emergency room alone, in the last 12 months.

Palomar Pomerado Health is preparing to build a medical center in Escondido that will have approximately 360 beds and 48 emergency room treatment rooms, compared with Palomar's 26. The new hospital is expected to relieve some of the pressure on Palomar, but that is not scheduled to happen until early 2012.

Contact staff writer Andrea Moss at (760) 739-6654 or amoss@nctimes.com.

Average wait times at North County hospitals in September: "Door to Doc" Total turnaround time

Fallbrook Hospital 42 minutes 3 hours, 3 minutes

Palomar Medical Center 39 minutes 3 hours, 3 minutes

Pomerado Hospital 38 minutes 3 hours, 1 minute

Scripps Memorial Hospital Encinitas 58 minutes 2 hours, 47 minutes

Tri-City Medical Center 24 minutes 3 hours, 46 minutes

Source: Area hospitals

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