When the University of Kentucky's new emergency room opened in 2010, Dr. Michael Karpf, executive vice president for UK's health affairs, compared the sleek new facility to a Ferrari.
Trouble is, the Ferrari is slow.
The average wait time for emergency care at UK — measured from the time a patient comes through the door until she is moved to a hospital bed — is 10 hours and 44 minutes.
That is the longest wait time in Kentucky, and 4 1/2 hours longer than the national average, according to Hospital Compare, a government website where Medicare crunches data on hospitals.
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The long wait time is a result of several factors, hospital officials say. ER patients and surgical patients competing for a limited number of in-patient beds and UK's ever-expanding number of patients have contributed to a bottleneck, said Colleen Swartz, chief nurse executive.
Karpf said he believes expanding the hospital by adding rooms and beds is the answer. Ultimately, he said, improving the wait times requires completing the $763 million medical tower that is currently half empty.
The Joint Commission, the independent non-profit which accredits and certifies more than 20,500 health care organizations, and Eugene Litvak, a Harvard professor and expert in hospital efficiency, say better communication, scheduling and staffing is the solution. Those methods, according to the Joint Commission, are "grossly underused."
More and more frequently, the crowded ER at UK results in dozens of patients being treated on beds lining the hallways, Swartz said. During a June 1 escorted tour of the emergency room for the Herald-Leader, 27 adults were on beds in the hall, with friends and relatives of patients perched on stools or chairs nearby.
Patients included some older folks with masks across their mouths, people with bones that had just been set. One patient, who was alone, had a pillow over his head.
What's the cause?
The primary reason UK has long wait times is because it treats the sickest patients with the most complicated cases, said Dr. Bernard Boulanger, UK's chief medical officer.
But the University of Louisville, the state's other adult Level 1 trauma center, has an average wait time of 7 hours and 5 minutes — 31/2 hours shorter than UK's.
Boulanger referenced Duke Medical Center, Cleveland Clinic and Vanderbilt University as taking care of challenging patients similar to the ones handled by UK. Still, patients at UK waited longer than patients at any of those institutions. (See accompanying graphic.)
The Joint Commission clocks the ideal wait time at 4 hours and concludes longer wait times "pose a persistent risk to the quality and safety of patient care."
Claiming to treat the sickest patient is "a classic explanation" used by hospital administrators, Litvak said. But the claim is not true, he said.
Building more beds is not the ultimate option for UK or for hospitals across the country with similar problems, he said. Adding and maintaining a single hospital bed can cost millions, he said.
With increased communication, hospitals can achieve an even tempo of patient flow that will reduce ER wait times, Litvak said.
Litvak worked with Cincinnati Children's Hospital from 2003 to 2009 to streamline patient flow. In an Aug. 30, 2009 story in the Boston Globe, Cincinnati Children's hospital officials said the improvements in efficiency allowed the hospital to treat as many patients as could be served by a $100 million, 100-bed expansion. Litvak said hospital income was also increased.
Cincinnati Children's current wait times are not listed on Hospital Compare because it is not a Medicare-certified hospital. But Nick Miller, a hospital spokesman, said the hospital continues to benefit from Litvak's methods. Litvak said that model can work as well in other places.
The main reason for a wait-time problem comes from how surgeries are scheduled, Litvak said. Surgeons like to operate early in the week, he said, and they tend to like to do multiple surgeries in a day. Also, surgeons tend to book operating rooms independently of the hospital's overall need to handle patient flow.
Often, Litvak said, surgical patients get priority over the ER patients. Surgeries are generally covered by insurance and are more profitable for hospitals. More patients in the ER are likely not to have insurance and are less profitable to treat, he said.
The emergency room patients suffer "because they are last in the food chain," Litvak said. And things don't change, he said, because "we don't want to upset our cash cows, the surgeons."
Sluggish patient flow out of an ER affects the entire hospital, increasing death rates, readmission rates, the rates of hospital-acquired infection, and the stress on staff, he said.
Some of Litvak's methods are used at UK to reduce wait times, Swartz said, and she agrees that surgery patients and ER patients can compete for beds at the hospital. But, she said, all UK patients are treated equally whether they have insurance or not.
Swartz disagrees with Litvak's position on adding beds as a solution. UK's situation is unique because of the significant increase in the number of patients coming to UK's ER, and that mandates more beds, she said.
Since the expansion of the ER in 2010, the number of ER patients has gone from 30,000 a year to 70,000 a year, she said.
The hospital is actively trying to reduce wait times, Swartz said. Each day a capacity team looks at where patients go throughout the UK Healthcare system and tries to get them to the right place for treatment as quickly as possible.
But volume continues to be a challenge. After the expanded ER opened in 2010 and for about a year after, Swartz said, there were no patients waiting in hallways. But, now, Swartz said, "it is a constant struggle."
Hospital Compare collects a variety of data about hospital use and "timely & effective care." In addition to tallying the amount of time it takes to get into a hospital bed, it also looks at how long it takes to see a physician and how long it takes before a patient is treated and sent home. UK is above the national and state average on those measures as well.
Problems of its own making
UK faces two problems of its own making. First, the expanded ER was designed with a pediatric wing that is never over capacity, said Swartz.
Dan Hamiltion, a spokesman for the American College of Surgeons, said there is a not a database that collects whether a pediatric ER exists in tandem with an adult ER. But, he said, it is not common.
Since the pediatric ER staff is specially trained to deal with children and the unit is equipped to deal with children, putting adults there is not appropriate.
So there are times, like during the June 1 tour, when dozens of adults are being treated in the hall while the pediatric unit has empty beds. The pediatric unit can't catch the overflow, said Swartz.
Plus, UK continues to actively recruit more patients to its system, many who come to the hospital through the ER. In June, Karpf traveled around Kentucky and into neighboring states to meet with hospital administrators to expand UK's network and draw more patients.
Should network expansion be put on hold until the ER bottleneck is resolved?
No, said Karpf. If UK doesn't court referrals at hospitals in neighboring states, for example, someone else will. And if those referrals go elsewhere UK will not become a world-class academic medical center on par with Duke, Vanderbilt and the Cleveland Clinic, he said.
While UK's message about building more beds is consistent among administrators, UK's own explanation about ER wait times is muddled. A slick brochure handed out at the annual board retreat in June included a graphic labeled "Timely Effective Care" and touted UK's overall ER wait time at 9 hours and 23 minutes.
That's because UK used six more months of patient data in its graphic than Hospital Compare and used all patients, not a sample, Boulanger said.
Although hard work with scheduling and patient flow temporarily decreased the average time by about an hour in just six months, that is not a sustainable solution, Boulanger said. Since the Hospital Compare data was updated in July, UK's ER average wait times increased by 21 minutes.
UK will shift 35 acute-care beds from Good Samaritan Hospital to the UK Chandler Medical Center by the end of the year. But Boulanger said those beds aren't sufficient to solve the problem in the ER.
Karpf says until sufficient beds become available, "we will have to muddle through" in the ER. The tower completion is set for 2018 to 2020.