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What Are We Waiting For?

By Chris Strear, MD, FACEP

I’ve found myself asking this question a lot during the COVID-19 pandemic, and on its surface, it seems like a simple and simplistic question. We’re waiting to see if cases ramp-up as states open up, or to see how bad that ramp-up will be; we’re waiting for more therapeutic options and for vaccination trial results; we’re waiting to see if the winter will bring a new wave even worse than the first; and we’re waiting for the time when things will feel normal again.

I practice emergency medicine in Portland, Ore. We’ve been incredibly lucky here—so far, our rate of cases is low and our volumes are manageable. But, many emergency providers in Oregon are waiting for the other shoe to drop. With our protests and rallies, and our insatiable quest for the perfect new brunch spot, what will happen here?

But for me, I want to understand the “things” we are waiting for now in our hospitals and clinics—the “things” that are making it tougher than it needs to be to take care of patients. I’m looking now for an answer to this question that can inform how we’ll do things better when next time rolls around.

In Theory of Constraints, Lean’s more handsome, lesser-known cousin, we identify a critical resource on which the entire system is dependent and change the system to improve our use of that resource. A shorthand for doing this, and a tenet for process improvement in TOC, is to identify the resources we find ourselves waiting for.

Some of the resources we keep waiting for have been grabbing the spotlight for the past couple of months—PPE, COVID diagnostic test kits and antibody tests, ICU beds and ventilators—and some are going to be in the news for weeks to come, such as effective treatments, vaccinations and comprehensive plans for widescale contact tracing.

At some hospitals in my city, there are times when there is only one critical patient waiting to move from the ED to the ICU, yet that wait can last for hours, even though the ED might be otherwise empty and the ICU has plenty of staffed beds. If we’re waiting hours for that ICU bed when there’s only one critical patient, what’s going to happen when there are six critical patients?

We’ve rearranged where we store equipment for resuscitations, so now there are times when we’re waiting for an endotracheal tube or a suction catheter, or even an extra pair of hands to jump in if things go south. Some waiting is unavoidable as we try to keep ourselves and our patients safe, but we must set aside some time now while we have it to identify critical resources we are frequently waiting for. When things go back to normal, we can figure out how to re-engineer our flow processes to make these critical resources more available and efficient. Then, we’ll be able to do even better when next time happens.

Improving flow is more important now than ever. Even under normal circumstances, there are a lot of changes we can make in our hospital operations that will improve patient flow. Often, relatively minor changes can have dramatic downstream effects, especially when these changes are focused on the most important resources. The key is to find those resources that will have the greatest effect on flow.

In the course of patient care, now is the opportunity to identify those resources that we find ourselves waiting for the most. Often, hospitals are either so busy that no one has had a chance to come up for air, let alone think about process improvement. Or, volumes are so low there’s no sense of urgency for process improvement. But this won’t last. Many of us are starting to see volumes climbing back. We might only have a narrow window between when volumes will stabilize, and when another surge will happen. We can’t afford to be complacent; we can’t afford to put patient flow on the back burner; and we can’t afford the luxury of postponing self-reflection over lessons learned the hard way. We’ve got to do better today because of what tomorrow might look like.

What are we waiting for?


Chris Strear, MD, FACEP, is currently the director of patient flow, as well as director of revenue cycle management, for Northwest Acute Care Specialists and is an attending emergency physician at a Level 1 trauma center in Portland, Ore.

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