Crash Cart: Toyota Speeds ER Discharges; Parents of Patients Can Be Present Says More ERs; Why ERs Get a Holiday Surge

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This week: Toyota tune ups ER discharge process, making it 40% quicker; ERs may stop ushering loved ones into “the other room”; There’s several reasons why ERs get a 5-15% increase around the holidays. Join in as our editors discuss the week’s headlines.


Toyota likes to help make nonprofits more efficient, so when the company came to Plano, Texas, Parkland Memorial Hospital CEO Fred Cerise got first-rate consulting that would have cost hundreds of thousands.

The consulting enabled its exceedingly busy ER to reduce average discharge time from 52 minutes to 31. Toyota’s team worked with nurse and other front-line staffers to analyze the process and come up with three big changes that took the lead out. Original Article by Dallas News.

William Sullivan, DO, JD: This is rather remarkable. Not because of the improvements in the process, but because the improvements didn’t come from a highly-paid consulting company. Good on CEO Fred Cerise for being more innovative than a typical CEO, but Dr. Cerise still has a lot to learn. I’d venture a guess that if the CEO just asked the ED director (or went to the ED and asked the staff) how to improve workflow, he would have gotten similar – and probably better – insights. It doesn’t take a foreign car company to pick out the processes that hold up ED throughput. And the thing is … Toyota *understands* that. One of the quotes in the article states “It’s all about empowering front-line workers … they’re the experts.” The real question that needs answering is why hospital management needs an outside consultant to appreciate the wealth of knowledge a hospital’s employees possess. I’m sure that there won’t be a follow up article, but I wonder whether these changes will adversely affect other aspects of ED throughput. In other words, by focusing more on the discharge process, will Parkland’s ED focus less on other aspects of patient care? BTW, Toyota agreeing to help Parkland only on the condition that the project not be used as part of a layoff plan – that’s a lot of karma points for Toyota in my book.

E. Paul DeKoning, MD, MS: Don’t totally disagree with Bill, but I don’t think this is a complete bust. Potentially a way for leaders in industry to share some of their expertise when it comes to systems and efficiency all while involving medical professionals in the process. But we need to be at the head of the table.

Ryan McKennon, DO: Sometimes it just helps to have someone from the outside to say the same thing. I think there are several reasons for this. One is that it can be difficult to point out areas that need improvement as it seems to “blame” other people you work with. It is much easier for an outside entity to say the time between discharge orders and the patient leaving the department is too long, if this comes from the director it can sometimes be interpreted as “the nurses are the problem.” Big corporations also seem much more facile at pulling relevant data from whatever EMR you are using. These large companies have spend billions in process improvement over the years, why not try and use some of that knowledge to improve our process, when applicable, and with cooperation and input from the department? Yes, yes, I know this is a utopia idea; call me an optimist.


On TV dramas, loved ones are usually whisked away when docs work frantically on patients. But increasingly, ERs and ICUs are allowing parents to stay with their child instead of ushering them into another room.

A nationwide survey recently found that 90 percent of Americans believe that by their side is the right place for them to be during a life-threatening injury or illness. While there are many upsides such as calming the patient or advocating for them and informing doctors of vital information, there are still issues that can arise. Nonetheless, some see the trend eventually carrying over to adults. Original Article by Healthline.

William Sullivan, DO, JD: I agree that having families present should be an option. However, there also must be a policy that if the family is disruptive in any way, they get escorted out. Families have pushed me out of the way, pointed fingers in my face, and (alleged) family members have given me incorrect information about a child’s medical history. Just last week I had a family member threaten me because I asked him to back up and stop recording me while I was trying to fix his son’s scalp laceration. He was literally putting the phone between my line of sight and the patient’s head. Then he repeatedly told his son “Daaaamn. Your head’s f***ed UP!” His son obviously became more upset, and repairing his laceration became even more time consuming and difficult. Parents can definitely be a calming influence on their children during an emergency, but we can’t assume that having family members in the room is always the best policy.

E. Paul DeKoning, MD, MS: “If your child were injured, would you want to stay with them while they received treatment?” Absolutely, no question, not negotiable. We actually do this pretty well here, including in activated traumas. The only time we may ask family to step out is certain sterile procedures or those involving radiation, like use of the c-arm for reductions, or if they’re disruptive and not-redirectable. And if mom or dad (usually dad) is likely to pass out in the process.


While CDC estimates indicate there aren’t actually more injured people during the holiday season, there are spikes in some common injuries and issues.

Among them: ignoring doctor’s orders, not enough sleep leading to muscular-skeletal problems, flu season, and emotional health. Original Article by Business Insider.

William Sullivan, DO, JD: Any time I read headlines touting the “inside scoop” on something that happens in the emergency department, I roll my eyes a little. Then I see that this article is trending on the Business Insider. Now I’m getting agida. A 10-12% increase in patients due to injuries playing touch football during Thanksgiving? Most years it’s too cold to play football outside by Thanksgiving. Injuries hanging lights? I see a couple of those a year. But do those types of injuries outnumber the sports or other outdoor injuries (bicycling/rollerskating/skateboarding) during the summer months? Doubtful. Intoxication is a year-round activity. Although alcohol-related ED visits are on the rise in the US (2.4 million in 2002 to 3.8 million in 2011 according to this study), I wasn’t able to find any data showing a spike during holidays. The uptick in ED visits during the winter holidays is probably due to three things: 1. There aren’t any doctor’s offices open during holidays. 2. Families visiting from out of town haven’t seen mom or dad for the past year and think that a gradual process since last holiday season is instead an acute issue needing immediate attention. 3. Influenza. Then again, telling people to plan ahead, visit their ailing family members more often and get influenza vaccinations probably would make for much of a trending article in Business Insider, would it?

E. Paul DeKoning, MD, MS: My ED is typically NOT tons busier on the holiday. Day after, yes. Day of, no. If scheduled to work a holiday and given the option, I’d definitely take the early shift over the later shift. Mainly because nothing else is open and social issues are harder to navigate. And don’t forget domestic assault as the day wears on. A bit off topic, but a great quote: “And if you do have to go to the ER, it’s best to bring someone along to help.” That’s just good advice any day of the year. Unless, you’re a doctor and a family member needs to go to the ED. In that case, stay home. Taking care of family members of physicians can be super painful–it’s so hard for us to not be the doctor. However, taking care of physicians is a totally different story. It’s true that doctor make terrible patients. In my experience, they’ll let you do whatever it takes to make them better.


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