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Cleveland Clinic making major changes to ER


For Holly Owen, wait times can’t wait. Owen, who took over managing the emergency department at Cleveland Clinic Indian River Hospital last fall as part of her role as director of critical care services, immediately went to work devising a plan to shave critical minutes off ED wait times while also improving patient privacy and quality of care.

The changes, expected to be complete by the end of January, will add 20 patient beds or treatment chairs to the current 44, streamlining the workflow and reducing patient wait times.

Improved care and comfort are also part of the plan.

A paramedic will now greet patients at the front entrance to identify symptoms of urgent concern. And at registration and discharge, clerks with portable tablets and printers will come to the patient instead of the other way around, sparing patients the effort of standing in line while shaving more minutes off the dreaded ED ordeal.

“It’s going to be drastically different,” says Owen, fanning the pages of a daily checklist that evolved out of multiple meetings over the past month. “We’ve had work groups with physicians, registration, techs, paramedics – everybody – so we can streamline the times and make the experience an excellent one while still giving quality care.”

In the new setup, nurses will be assigned patients in specific beds, as opposed to keeping track of them as they move from one process to another.

“Right now, everybody’s everywhere and these poor nurses are having to hunt around to find their patients,” Owen says. “Under the new system, that nurse or physician will know who’s in their section.”

That system is already used in the section reserved for the sickest emergency patients, the ring of rooms built in 2004 that are behind double doors and down a corridor from what is now the public waiting room. Less acute cases are relegated to a small waiting area behind the registration windows, a cramped space where nurses and med techs weave among a maze of patients seated side-by-side with a range of maladies. On difficult days the area becomes a crucible of misery that Owen calls unacceptable.

By the end of this month, the ED space will be unrecognizable, reconfigured in a rapid-fire renovation to include private patient bays, leaving only a narrow corridor of chairs for visitors and family.

“A waiting room is not where we want to care for our patients,” said Owen, who has made a point of dropping by the waiting area multiple times a day to reinforce her commitment to change.

As the ED is reconfigured, the registration windows at the rear are being eliminated, doing away with a process Owen called “somewhat dysfunctional.”

“Going forward, full check-in will be done not at a window but in the private bay or room. People don’t want to be directed to a window, they want to see a person,” said Owen.

“We will come to you. You’re pretty much concierged through the whole process.”

According to Cleveland Clinic Indian River’s data analysis, the ED had around 65,000 patient visits in 2018 and 2019. That’s a substantial increase from 2015 when Owen first started at the hospital, she said. Since that time, the ED has undergone a series of staffing changes, at times contracting with workforce providers for physicians and mid-level managers. Currently it is under contract with Envision, a national company.

Dr. Brian Wiley is Envision’s director of emergency services at Indian River. A veteran of 12 hospital emergency departments, he started in Vero in February 2018.

“We came in because they were having a lot of issues with the ED,” said Wiley. “Within that first year, we made a lot of substantial improvements with our turnaround times, quality and patient satisfaction. Now we’ve hit an impasse and we’re going through more changes which includes increasing our bed capacity. We can’t increase the physical plant, but we can increase the number of spots we have.”

Wiley called Owen “a driving force” in improving the emergency department.

“With Holly coming on board, we’ve really pushed to make that area more patient friendly.”

Envision currently has three years left on a five-year contract, though the staffing arrangement is subject to periodic review.

“We have evaluation periods within that [five-year period] so we can give them a 90-day notice [if the hospital wants to make a change],” said Cleveland Clinic Indian River chief operating officer Dr. Ralph Turner. “Right now, we are in that evaluation phase. We are evaluating constantly to determine if we keep them or bring in another contractor or do it ourselves.”

Elsewhere in the Cleveland Clinic Florida system, Martin Health hospitals contract with another company, Team Health, to staff ED physicians; Weston uses Cleveland Clinic-employed physicians.

At Indian River, many of the 18 ED physicians worked at the hospital prior to Envision, when the hospital employed its own doctors and before that, used a different contractor. 

The changes in the emergency department began in concept in April, when a Cleveland Clinic Florida team arrived in Vero from the Weston headquarters to take a hard look at Indian River’s ED.

“They did a very detailed recommendation for us and we are actively working on that,” says Owen. “This is part of that integration.”

With its 65,000 patients each year, Indian River’s emergency department is considered “very high” volume, according to the Center for Medicare and Medicaid Services. Lawnwood Regional Medical Center’s volume is also considered very high, while Sebastian River Medical Center’s volumes are considered average.

Despite the much higher volumes, both Indian River and Lawnwood had lower median wait times than Sebastian River for patients who ended up admitted to the hospital. But wait times for patients sent home were longer at Indian River: 166 minutes as compared to 123 at Lawnwood and 127 at Sebastian River. Those figures were from 2018, the latest available from CMS.