In India, emergency medicine gained the honour of being a speciality in medicine only in 2009. Most emergency rooms (ER) continue to be staffed by untrained physicians and are called ‘casualties’ to date. But amidst this, there is a dichotomy developing with several private and public institutions pushing for responsive and accountable emergency care networks and investing in world class facilities of care. With the emergency care delivery systems still in their nascent stage in India and ER admissions accounting for a growing proportion of inpatients in hospitals, there exists a unique opportunity to make these systems patient-centric. The potential issues of tomorrow can be addressed today!
Patient don’t really know what they want – The myth of medicine
Complicated medical jargon, squiggly scripts and arcane latin-y phrases – coupled with arrogant smirks, and a conversation that started and ended with ‘I know best’ – that should pretty much sum up at least one of our experiences with physicians and surgeons. Somewhere, somehow, we as healthcare providers have propagated and continue to believe in the ‘myth of medicine’. A myth that empowers us to feel ‘all knowing’, ‘all powerful’ and consider everyone else as ‘the common man’. The truth is however disparate from this created fantasy of ours. An increasing number of patients and their relatives understand healthcare, disease processes, care protocols and are able to discern excellence in care delivery. Care delivery is no longer a myth, but a care experience that is more than the sum of its parts. It is no longer just about good clinical care, but also about the people (the way they communicate, the empathy they display, and the way they treat each other) and the place (the look-feel-sound-smell, the privacy and the comfort afforded).
Sombre white walls with green curtains and eerily silent staff are not even found in TV series and movies today (albeit they still continue to be disconnected from the ‘actual’ practice of medicine). More interestingly care experiences are no longer limited to the four walls of treatment areas. Convenient access to areas that enable visiting friends and worrying families to regain fresh-air, the way hospitals/clinics conduct both clinical and non-clinical business all make a difference to the care experience.!
Patient centred care in the emergency room … Life goes on
Let’s start with an ER experience example that most of us can potentially relate to. Consider a patient with a bad lung infection that has presented to the emergency room with falling blood pressure and decreasing urine output. The worried family is asked to step out of the treatment area and find someplace to wait in the emergency room where ‘they don’t interfere in the care being delivered, and allow the doctors to do their job’. The patient is rapidly assessed by the treating physician to be in septic shock and as he prepares to initiate appropriate antibiotics and perform procedures to augment the blood pressure of the patient, a nurse quickly comes to the family handing them a sheet to take to the admission desk to admit the patient in the ICU ‘quickly’. The family member most experienced with hospitals finds the admission desk crowded with many other admission applications in an area of the hospital that is accessed by taking the first right and the second left turn out of the ER. A few minutes of wait later he is asked to deposit a certain amount of money to ‘make the admission’ of the patient. A few calls and a short walk to the ATM later the money is deposited and the admission file is created. Meanwhile the physician in the ER quickly explains to the other family members that the patient has a severe infection and will be monitored in the intensive care unit (ICU) for potential affliction of the kidney function. He counsels them on the potential need for ventilation and is in the midst of explaining the next course of action when suddenly a trauma victim is wheeled into the ER in front of everyone’s eyes. The physician rushes off to ‘handle’ this critical patient. As the family tries to discuss their next steps the patient next to them vomits on the floor and a child starts wailing in another treatment area. A security guard walks up to them and telling them to clear the ER as ‘only one attender is allowed per patient’. At the same time two nurses walk into the patient’s area and ask him to change out of his clothes into the mandatory ICU gown. As soon as this is done the radiology technician arrives and helps the patient remove the ICU gown to take an X-ray of his lungs. Within an hour the patient is shifted out of the ER into an ICU where a specialist takes control of his management.
As you read the above, reflect on the quality of care delivered and the satisfaction with the care delivered. Are these two distinct questions? Does excellence in one guarantee the other? Does failure to deliver one of the two trigger a collapse in the satisfaction level of patients/ family members?
The overwhelming belief that many healthcare planners have is that only the quality of care matters during medical emergencies. There is no denying that there are significant challenges to delivering on patient centred care in the ERs. Overcrowding, lack of a relationship between the ER staff and patient families, the social and cultural pressures of a patient arriving in an ambulance, time sensitive nature of interventions and procedures, triaging etc. each have their own ramification on delivery of patient centred care. At the same time though, it is never impossible to deliver care that is based on common sense and is conducted with respect and empathy. The fundamental premise that a care experience is determined by the people, the place and extends beyond the treatment areas remains true even here, and it all starts with understanding what patients and their families really want!
What are patient expectations during medical emergencies?
This brief study identifies patient preferences and needs during medical emergencies – and these end up being very similar to the basic tenets of patient centred care. (Check tables)
What is the recipe for patient centred care in the emergency room?
Indian cooking often has the phrase ‘add as per taste’ in front of components of a spice mixture. Similarly, there is no absolute recipe to deliver patient centred care during medical emergencies, but highlighted below are the major components that should definitely be assessed and addressed at any institution that is committed to delivering responsive care to patients. (Check Figure 1)
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Patients whose last hospital visit was to an Emergency Room
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| When did you visit the Emergency Room? | Top three reasons why you chose this hospital | ||
| < 1 month |
34%
|
Skill & competence of staff |
69%
|
| 1-6 months |
28%
|
Technology in hospital |
28%
|
| 6-12 months |
10%
|
Time it takes to get care |
24%
|
| > 12 months |
28%
|
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| Type of hospital you visited | Time taken to get care was | ||
| Corporate |
69%
|
No wait |
41%
|
| Government |
4%
|
Shorter than expected |
17%
|
| Nursing Home |
10%
|
As expected |
28%
|
| Not-For-Profit/Trust |
17%
|
Longer than expected |
14%
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The right people
When talking about the people who deliver care during medical emergencies, it’s important to remember that this is not just the physicians and nurses who take care of patients inside the emergency room. Meaningful engagement of patients and family members in care delivery is essential as a first step to treating patients with respect and integrity. A few implementation steps that can move the needle in the correct direction are:
No strangers
- The care team should introduce themselves and their roles in a lucid and memorable way. Putting up a magnetic board with small photographs and names of the care team could possibly help patients remember who is taking care of them in what capacity.
- In a rapidly changing scenario of medical emergencies, it may be useful to have some constant. A patient care coordinator allocated to a particular family would be a good start to establishing a relationship between the ER staff and the patient family.
Family participation
- Allow patients to define who would be part of his/her family – and offer to speak freely to family members who maybe healthcare practitioners themselves if the family should like.
- Care team should ask these defined family members at the very outset as to how involved they would like to be in the patient care decisions.
Trust in qualified personnel:
- Hire qualified individuals who have the requisite expertise in emergent medical treatment. It is also important to display the same to patients – displaying expertise by demonstrating journal publications, interest profiles etc. of physicians and nurses may be a way of doing this. Excellence and Outcomes are markers of expertise. Public reporting of outcome measures may be a good strategy to enhance trust in care delivered and in the people delivering the care.
- Have a hierarchy of staff, to ensure that patients have a way to escalate questions if they should like.!
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What patients like and want in Emergency Rooms
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| Top five things that you liked about the ER you visited | Top five things that you would like all ERs in India to have | ||
| Promptness in delivering care |
44%
|
Trained physicians and nurses |
45%
|
| Attitude and attentiveness of nurses and physicians |
40%
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Special areas for treating high severity diseases like heart attack, brain stroke, infection etc. |
38%
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| Availability of advanced equipment in ER |
37%
|
Technologicaly advanced equipmen |
37%
|
| Competence of Physicians |
32%
|
Appropriate communication about possible delays in testing/bed availability etc. |
21%
|
| Time taken for administrative procedures |
26%
|
Separate quick treatment areas for minor illnesses |
17%
|
| Cleanliness |
19%
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Cleanliness |
14%
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| Communication |
14%
|
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| Not-For-Profit/Trust |
17%
|
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The right place
The structure and plan of the emergency room should ensure privacy and comfort for both patients and their family members. The emergency room should also cater to the satisfaction and comfort of their own staff members. Bed clusters grouped by disease acuity/ patient stay duration with dedicated nursing/physician areas for each have shown to improve nurse-patient interaction, efficiency, safety and quality of care delivered. A well structured emergency room should incorporate at least the following treatment and nontreatment areas:
- Triage
- Dedicated high acuity-trauma resuscitation
- Intensive care unit
- High severity disease management area (if possible then segregated by disease type)
- Fast track/ chair disposition area for minor illnesses
- Isolation/ decontamination area
- Procedure room for minor procedures
- Staff lounge
- Waiting area with access to coffee/snacks, counseling rooms, and a multi-faith chapel/prayerroom.
- Adequate patient and staff restrooms at distributed accessible locations
- Paediatric emergency area
- Observation area for patients staying in the ER > six hours.
- Billing and central registration areas
- Outpatient pharmacy
- The nursing/physician areas should have minimal physical barriers for interaction with other staff and family members.
- Regular upgrade/ service of equipment and introduction of advanced effective diagnostics such as point of care testing and ultrasound not only help to streamline care delivery and decision making but also help convey to patients the technological superiority of the emergency room!
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Some factors that determine behaviour of patients
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| What is the most important factor in your choice of an ER | Do you use the internet to make decisions about which hospital or physician to visit? | ||
| Nearest hospital |
36%
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Yes |
17%
|
| Prior personal experience |
30%
|
Yes but only for second opinions |
39%
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| Reference from family physician |
20%
|
No |
43%
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| Reference from friends |
14%
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| Do you use the internet to read about diseases/treatments? | Do online reviews about hospitals/ doctors influence you in your choices? | ||
| Yes, always |
54%
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Yes, strongly influence |
16%
|
| Yes, but infrequently |
38%
|
Yes, but weakly influence |
41%
|
| No |
8%
|
No |
43%
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The right care and the right way
Care during medical emergencies is both medical and psychological, and is both for patients/families and the staff themselves. While clinical care is an essential component of this, more often than not it is the effective communication aspect that gets ignored in busy emergency rooms. Attitude often trumps competence in medical emergencies. Some ways to build trust in the care being delivered include:
- Display boards that allows patients to access personalised information on waiting times, care plans, pending and completed diagnostics – referrals etc. These would aid patient-family engagement as well, especially during times of ED crowding when practitioners may not be able to spend as much time with patients.
- Development and deployment of communication plans: Introduction of scripting tools for communication, and Initiatives such as the HEART initiative (Cleveland Clinic) that encourage staff to display sensitivity when patients/ families have complaints have been proven helpful in alleviating concerns and improving satisfaction.
- Summarising patient findings to consulting specialists in presence of patients/ family members themselves, so they have the opportunity to add/correct facts when required. This would also prevent the multiple times a patient is required to give a history within the current medical system.
- The most commonly ignored care in the ED for patients is ‘food’. Creating a system that responds to patient food requests with extraordinary agility is likely to improve the care experience significantly.
- Assisted navigation through administrative processes by patient care coordinators.
- Remembering and addressing patients by their names/a name they would like to be called by.
- A continuing review of patient expectations and responding to them.
- Most hospitals and healthcare facilities today understand patient outcomes and monitor the clinical quality of care, but forget to measure satisfaction with the care-experience.
- Asking the right questions at the right time is essential to conduct these care-experience reviews. While there are several standardised tools available to gauge patient satisfaction with care levels, often these tools are often applied at the time of discharge only. Taking a leaf from lean-six sigma, every single process of care needs to be reviewed at the time it is performed and not once the process is complete.
- Response to issues found in these reviews should never be knee-jerk reactions. They should be structured both in thought and in operational feasibility to ensure that there is a minimal tradeoff between providing comfort to families and delivering quality care.
But…
As you read and start reflecting on the above, some common thoughts that may come to mind are:
“All this sounds great, but have you been inside a busy emergency room? Where is the time?”
“I can’t do this alone without backup of my hospital”
“Patients and families always want more”
“All this is good for the west, in India whatever the doctor says is the word of God”
“We will never have the resources to deliver this type of care in India”
“Patients don’t even seek care in time in India, where is the opportunity for patient centered care then?”
“All patients care about is money, if you lower the costs they will be happier than ever”
The list can go on and on…
What every healthcare administrator and practitioner needs to accept and acknowledge first and foremost is the fact that ‘delivering patient centred care’ is not ‘rocket science’. In the end patients want what everyone wants, better care, better outcomes and a better experience. We may all practice in a developing part of the world, but that in no way entitles our customers to a sub-par experience.
The patient centred care delivery initiative not only improves patient and staff satisfaction but also translates into improved safety, quality measures and an increased sense of empowerment for both.
An organisation that adopts these principles and works towards them would definitely hold an edge over its competition for patient retention and return. In the end satisfied patients will always continue to be the cheapest and most effective tool for business development and competitive advantage.