Cambridge Health Alliance emergency room procedures have been revised since 2006, becoming a model for other health providers.

As Cambridge Hospital expands and upgrades its emergency room for the first time in years, the hospital has quietly transformed itself into one of the most efficient emergency departments in Massachusetts and a model for other hospitals across the country. The Cambridge ER has the shortest waiting time in the state for a patient to see a doctor or nurse-practitioner: an average of roughly 10 to 12 minutes from the time someone walks in the door, says Dr. Assaad Sayah, chief medical officer for Cambridge Health Alliance.

Dr. Assaad Sayah

Sayah

It would be a surprise to patients using the service 11 years ago, when Sayah arrived. Then, “we ranked in the bottom [10 percent] in state and national patient satisfaction,” he said. The emergency department also scored low on performance measures such as the number of patients who left before being seen by a doctor, the hours they had to wait if they did stay and the amount of time the emergency room was so backed up that it turned away ambulances.

Sayah, who had worked in emergency services at Brigham and Women’s Hospital, St. Elizabeth’s Medical Center and Caritas Good Samaritan Medical Center in Brockton, was hired by Cambridge in 2006 to head the emergency department – and to turn things around. He and teams of doctors and nurses inside and outside the emergency room worked for 18 months to come up with a “process improvement plan” to streamline the flow of patients from the time they arrived until they were admitted to a hospital bed or discharged after treatment.

The changes cut the average time patients spend before being admitted, transferred or discharged after treatment almost in half, raised patient satisfaction and eliminated the need to divert ambulances two years before the state imposed a ban on diversion, according to a 2014 research paper for which Sayah is the lead author. The changes have been rolled out at all three Alliance hospitals, in Cambridge, Somerville and Everett.

Psychiatric, 24-hour needs

The Health Alliance is expanding the Cambridge Hospital emergency room, adding six rooms to the current two dozen.

One major reason is that psychiatric emergency patients still wait far longer than others, even though the overall average wait has dropped. That ties up rooms and “more and more patients are being put in hallways,” Sayah said. And that happens even though Cambridge Hospital has its own psychiatric beds, he said.

“It’s outside our hands,” he said. Insurers hire separate companies to administer mental health benefits, and they may have lengthy procedures for approving admissions. MassHealth, the state health care program for poor people, covers the majority of Cambridge Hospital psychiatric patients. It has its own time-consuming approval process, Sayah said.

“Let’s say I [as an ER physician] know for a fact this patient is not safe to leave and requires an inpatient admission,” he said. MassHealth still “needs to send one of their own organizations to do the screening.” The screener, not a medical professional, has to fill out a 20-page form. “They take their time,” Sayah said. Even though Cambridge is one of those screening organizations, the form must still be filled out.

As a result, what might take no time for a medical patient will take five to six hours at best and five to six days at worst for behavioral health patients, Sayah said. “Our society has allowed this,” he said, referring to the lengthy approval process.

In addition, the hospital needs to have more rooms appropriate for psychiatric emergency patients after eliminating its separate psychiatric emergency service three years ago, a move that drew criticism from patient advocates and city councillors.”We needed to create more private space for behavioral health patients,” Sayah said.

Finally, the Cambridge emergency room has not been upgraded after operating 24 hours every day for two decades, he said. The all-day operation means “stress on the physical plant is 10 times greater” than that on a space that’s open only during business hours, he said.

Patients can be less patient

A worker does patient triage at Somerville Hospital.

Most of the process improvements made in 2009 are still in effect today. The most obvious is what happens when patients walk into the emergency room: a “patient partner” greets them and asks for just three pieces of information – name, Social Security number or date of birth, and what’s wrong.

Patients then go immediately inside to doctors, nurses or nurse-practitioners who assess how serious the problem is, complete the registration process and treat those with minor complaints, all in one area called a “rapid assessment unit.” Those three functions used to be handled separately in separate places. Patients with serious injuries or illness are taken to an ER room for more extensive treatment and tests.

The main change, Sayah said, was “we put the patient in the middle and we all move around the patient.” Conventional emergency room procedures force patients to move from step to step, often returning to the waiting room in between, and repeating their stories to multiple clinicians.

There were other less obvious changes to speed up and improve treatment; for example, nurses and doctors identified patients early on who were likely to be admitted to the hospital, and the admission process was streamlined. On the other end, doctors and nurses in inpatient units quickened the discharge process when the ER was full.

Teaching hospital

Health Alliance emergency rooms minimize the “handoffs” of patients from one clinician to another.

As a result of the changes, Sayah said, the average time for patients to be admitted, transferred to another hospital or discharged has dropped from 220 minutes – almost four hours – to less than 130 minutes, or two hours and 10 minutes. “We were able to do things more efficiently” and see more patients with the same staffing levels, he said. “We minimized the number of handoffs” of patients from one clinician to another, he said. “That improves quality because every time you hand off you can miss something.”

“Patients like it,” he said. In the 2014 research paper, Sayah said patient satisfaction scores increased from 12 percent on a national scale to 59 percent after the changes.

Sayah said people from other hospitals “visited us to learn” about the process at CHA. He has written several papers on the improvements published in clinical journals and has spoken at conferences; in May, he will be on the faculty for a training program offered by the nationally recognized Institute for Healthcare Improvement. His topic: improving hospital flow.

Sayah wrote in 2014 that it was difficult to change processes in the emergency department “for many reasons including culture and history.”

“Part of the reason why so many hospital EDs follow such hopelessly inefficient patient flow standards has been the … thinking that ED patterns are intractable and cannot be solved” without spending a lot of money for more space and staff, the paper said. Cambridge has “discovered that ED transformation is manageable, strategic and inexpensive.”