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Dialing Down ED Wait Times

Nurses find promise in pilot study is looking to telemedicine to decrease emergency department overcrowding.

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Since early spring, some patients seen at UC San Diego Health System's emergency department have been greeted by an unusual sight: their doctor welcoming them from a TVscreen miles away, transmitted from home, office or on vacation, thanks to the magic of telemedicine.

A few months ago, the health system became the first in California to participate in a pilot study using telemedicine as a way to decrease ED overcrowding.

"Telemedicine has been around for a while, but it's never really been used in an ER setting," said Benjamin Guss, RN, lead nurse on the project. "Our ultimate goal is to decrease wait times and take care of patients in a safe way."

The Reality of ED Overcrowding

Even as more and more hospitals are advertising shorter wait times in their emergency departments, the reality is that ED overcrowding still exists on a large scale.

In fact, according to the most recent report on ED wait times by Press Ganey, average wait times are continuing to increase - pushing up to four hours, seven minutes in 2009.


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Hospitals are searching for solutions. Some are working on improving processes, including having doctors see patients first, so that those with more minor conditions who don't need tests can be discharged quickly. Others triage patients with non-emergent issues, then match them with a primary care provider for a follow-up appointment.

Guss's father, David Guss, MD, chair of the Department of Emergency Medicine at UC San Diego School of Medicine and the study's principal investigator, saw a different solution - one that involved technology that has more traditionally been used to reach out to rural locations without specialty physician support.

"Working in an emergency department opened around the clock, you never know who may come through the door, so you are constantly faced with the challenge of matching staffing resources with the demands for care," said Dr. Guss. "If the use of a telemedicine evaluation can be shown to be safe and effective, it may shift how care in the emergency department is delivered."

Telemedicine Pilot Study

The project, Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency (EDTITRATE), took years of thought and planning, and when it came time to launch,

Dr. Guss's son took up the torch to lead the project from the nursing side. His role is not only to be the lead telemedicine nurse, but to also train other nurses on how to use the technology and how to manage the workflow.

ED nurses play an important role as they are the go-between for the onsite patient and the off-site physician.

Here's how the study works: When the ED grows busy, nurses participating in the study assess the acuity level of patients in the waiting room.

For the purpose of the study parameters, they select patients with less emergent conditions, who typically would experience lengthy wait times.

While the telemedicine project could ultimately see any type of patient, said Guss, influenza, ankle pain, back pain or abdominal pain, cuts and scrapes are just a few examples of the types of problems they've treated.

"The [telemedicine] doctor can do everything you need to do on site, other than physically touch the patient," said Guss.

Residents perform any suturing or specialized exams that may be needed, such as pelvic exams, and the telemedicine doctor also provides a report to an onsite attending after each visit, who meets with the patient to discuss the findings and diagnosis before discharge.

Six ED rooms are dedicated to the project, with one mobile telemedicine unit. When the off-site doctor is paged, the doctor can log in from anywhere with an Internet connection, and the patient is seen within minutes.

The telemedicine unit is equipped with two cameras, including a main camera that the physician or the nurse can control on either end, which zooms in and out and scrolls up and down.

The nurse can also manipulate a handheld camera so that the physician can examine skin or throat problems, for example. Other tools include an audioscope and a stethoscope that transmit images of the inner ear and heart, lung and abdominal sounds to the offsite doctor.

Both doctor and patient can speak to and see one another via the unit; in addition, the doctor can easily go online to view the patient's medical records, including test results and X-rays. Throughout the process, the nurse has a dual advocate role: to be physically there for the needs of the patient; and to be the doctor's onsite eyes, ears and hands.

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Challenges & Successes

So far, about seven nurses and 10 doctors are involved in the pilot study. The most difficult challenge has been managing the workflow involved on the study side, but overall.

"It's incredible promising," said Ryan Johnson, MSN, RN, ED staff nurse, who says that the technology wasn't difficult to learn. "And the nursing demands are not much different at all from what a nurse would normally do with a regular ED patient."

While the pilot study only sees about five patients at this point during a four-hour period, Guss said there has already been a impact on wait times and provider stress. "It's looking really good," he said (data from the study will be presented in October at a meeting of the American College of Emergency Physicians).

"As an extra nurse on the floor, seeing four patients at a time with telemedicine, it relieves stress in the waiting room, stress on the triage nurse, and the [onsite] doctors basically are not having to see as many patients as they would have."

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One unexpected benefit has been improvement in nurse-physician communication.
"There's a lot of teaching that goes back and forth [between the nurse and the offsite doctor], and coordination of care," said Johnson. "[As a result], with non-telemedicine patients on normal days, the working rapport with attendings is better than it would be otherwise."

But the biggest benefit, said Guss, has been in patient satisfaction.

"Right now, the scores we've received have been off the charts," he said, adding that some returning ED patients actually ask for telemedicine. Patients not only appreciate the close one-on-one contact with the physician and nurse, but also appreciate how much they can be involved in their own healthcare, since a video screen in the room shows them everything the off-site doctor sees.

"For the first time, they get a really close look at what their throat looks like," said Guss, as an example.

According to Guss, it will take more time and additional studies before they can fully determine how cost-effective and feasible ED telemedicine might be on a broader scale. Plans to grow the project are already in place:

At UC San Diego, they will soon add another telemedicine unit for the health system's second ED in La Jolla. But with early results being overwhelmingly positive, don't be surprised if telemedicine becomes more widely considered as a viable solution for the growing problem of ED overcrowding and wait times.

Danielle Wong Moores is a freelance writer.

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