From Room to Department

Anniversaries invite review of the past and visions for the future. As HEALTHCARE DESIGN celebrates 10 years, it is interesting to look back—from a former emergency department nurse’s perspective—at how emergency departments have evolved and—now, from a healthcare advisor’s perspective—how lessons of the past and new research are optimizing staff performance and the patient experience.

Emergency medicine has made great strides as a specialty practice since the first residency programs began in the 1970s. The role emergency departments play in the healthcare delivery system has become pivotal in the day-to-day delivery of care. Its importance is demonstrated by the overwhelming number of articles, research studies, focus groups, national reports, webinars, and blogs on the subject. It is amazing to examine the progression.

ER to ED evolution

Back in the 1970s and 1980s, the “emergency room” (ER) had more open bay beds than private rooms, less medical equipment, fewer staff on duty, and there was no need for large waiting areas. Board-certified emergency physicians were not the norm, nor were nurses specially certified to handle the vast range of patient ages and clinical cases. Finding specialists for referrals was easy compared to today.

Fears of bioterrorism were uncommon, though mass casualty drills were routinely conducted. Patients’ throughput was tracked by “where” the chart was placed. High-tech equipment included cardiac monitors, and glucose monitors and dip sticks were the point-of-care testing. As demand increased, dedicated X-ray technicians were appointed, but ERs still depended upon remote printouts or phone calls for diagnostic test results.

Yesterday’s ERs typically had easy lines of sight and earshot from the nurses’ station, at the expense of patient privacy. Nurses manually managed supplies, routinely mixed medications, obtained long histories at triage, and had time to hold patients’ hands. Nurses spent considerable time walking—looking behind curtains for physicians or care team partners, or back and forth to the supply cart, telephone, or unit secretary desk. There were few delays in getting patients to an inpatient bed, and mental health patients were easily transferred to community resources.

The 1986 Emergency Medical Treatment and Labor Act, the unfunded act granting rights to emergency care for everyone, was a key trigger to ER volume growth. As hospitals adapted to keep up with escalating volumes, the importance of emergency services received greater recognition with the development of trauma systems to expedite response times and heightened awareness of the role the ER plays in meeting business and community commitments. The ER’s new demands necessitated specialized care providers to expand its capabilities.

New “product lines,” such as observation beds, chest pain centers, and fast tracks, were developed to improve patient throughput. The ER became a recognized hospital “front door,” and thereby its impact on user satisfaction and hospital reputation gained more attention. With this transformation, the ER matured into the “emergency department,” (ED) signifying its broader impact on healthcare business.

Since the 1990s, we have seen continued growth in the volume of people seeking emergency care, while the number of hospital EDs has decreased and access to inpatient beds has lagged. In 2006, the Institute of Medicine proclaimed that our EDs were in crisis. AHA Trendwatch reported growth in ED utilization rates increased from 351 visits per 1,000 in 1991 to 415 visits per 1,000 by 2009. During the same period, the number of hospital EDs decreased 10% and the number of hospital beds shrank by 198,000.