Emergency department tops state rankings

When the state's surveyors ask you to speak at a national conference to teach other small hospitals how to emulate your emergency department, it's a good sign your efforts are bearing fruit.

"Five years ago, we were basically a band aid station," says Bob Hart, RN, who heads up the trauma department at Crook County Memorial Hospital. "Now, we can recognize, stabilize and rapidly transfer out critically ill and injured people."

Hart, along with emergency room nurse practitioner Warren Shaulis and Heith Waddell, MD, has been asked by the Wyoming Trauma Program to attend the Rural EMS and Care Conference in April, 2020 to explain how the drastic improvements in the hospital's ER have been achieved. Crook County Medical Services District is now a gold-star example of getting things right according to the survey crew's standards and that example will be used to help critical access hospitals around the nation do the same.

"They were very impressed with how much we had improved our patient care," says Hart.

"Not only that, the facility has improved a lot as well. We have a new ER and education has been brought up a lot. It's been about a five-year process working to get to this point."

Improving an emergency department is all about minimizing the amount of time between a patient getting injured and reaching a surgeon who can provide definitive care, says Shaulis.

"There is an old saying that trauma is a disease of bright lights and cold steel. In other words, it's a disease of surgery," he says.

"Anything that we do on an ambulance or in an ER is temporizing the patient. In other words, we're just trying to keep them alive long enough to get them to a surgeon – to definitive care."

This has been the overall goal in America's hospitals for over half a century, he adds.

"There was a paper written back in the 1960s by the National Highway Traffic Safety Administration. It said basically that a soldier in Vietnam had a better chance of surviving than somebody who was injured in a car accident on the highway in the United States," Shaulis explains.

"The military had a better evolved trauma care system developed, they had helicopters to fly people. That's where this all came from, is that very seminal paper."

The state surveyors have certified Crook County's emergency department for another three years, says Hart, and the staff are proud of the statistics on which that was based. Accreditation is judged on a list of criteria, he says; for example, turnaround times.

"We've drastically decreased our emergency department dwell time. That's the time the patient spends here. We accomplish what needs to be done in a much shorter period of time now," Hart says.

In fact, the ER has one of the fastest turnarounds in the state, well above the average.

"For our trauma team activations that are inter-facility transfers, we're at 105 minutes and the state benchmark is 120 minutes or less," says Hart.

Another criteria is for the entire trauma team to arrive on scene and be ready to go within 20 minutes, even at night. The average for Crook County's ER is 15 minutes, Hart says.

The state also requires the department to be able to properly determine when the trauma team needs to be activated. If, for example, a young and healthy person trips over the sidewalk and is brought in for a minor twisted ankle, calling in the trauma team would be an overreaction – or 'over-triage'.

"If you were to call the trauma team every time the ambulance goes out on some type of an injury, that would be considered over-triage – in other words, you're activating the system too often," Shaulis says.

Over-triage is not, of course, nearly so serious an error as under-triage, which is considered to have happened when the trauma team fails to react to a serious situation.

"Their criterion is that over-triage should not exceed 50 percent and under-triage should not exceed five percent," says Hart. "We are at 32 percent over-triage and zero percent under-triage."

All criteria are adapted for the type of emergency department in question. Crook County's hospital does not have a resident surgeon, so its staff is tasked with stabilizing and transferring patients.

This places it at a lower rung on the hierarchy than some of the bigger state facilities and impacts the goals the ER is expected to achieve. According to the U.S. Department of Agriculture, the hospital is considered 'level four frontier'.

"That means we have a population assessed by the U.S. Census Bureau of less than 2.5 people per square mile for the whole county. We also have a distance from any larger suburban areas, so we're providing exceptional care in a very frontier area with minimal resources," says Shaulis.

Not every injury requires surgery, of course, and some patients no longer need to be transferred, largely thanks to the presence of Dr. Waddell. This is figured out during the in-depth evaluation process.

The drastic improvements that have taken place over the last five years are centered around two big changes: a new, updated trauma department built to streamline the process of treating a patient during an emergency, and the staff-run ambulance service.

"We have advanced life support staff here in the hospital 24/7, so they work side by side with the critically trained nurses and the ER. It's really gives quite a bit of bench strength in the ER," says Hart.

Around and between these changes, much work has been done to stitch the whole system together.

"The new facility is nice, but this is really geared more towards patient care: the staff that takes care of the patients," says Hart. "Education and training and we do a lot of drills to make sure we're prepared, and a lot of putting policies and processes in place."

Hart himself has taken the lead on most of this work, Shaulis points out. The support structure assisting his efforts run through the entire organization, from the Board of Trustees and CEO through areas such as IT, purchasing, billing and the emergency healthcare providers themselves.

"We're also trying to build some partnerships externally with our local EMS partners who aren't here in town – Hulett, Pine Haven, Moorcroft, Upton – as well as building relationships with the referral centers we end up sending patients to," he says.

"We're getting much better information back from them now, so we're able to do quality improvement and evaluate our care based on those numbers and that information as well."

While the department is satisfied with its progress, says Hart, that doesn't mean the work is complete.

"We can't let up. If you let up, you're going to backslide, so you keep pushing forward, especially in the areas of education, staff and to start branching out into the community a little," he says.

The community aspect will include such things as Stop the Bleed, a national initiative that the State of Wyoming has embraced to teach people what to do if someone is bleeding heavily. Public involvement in a person's care can make them part of the chain of survival.

However, all three are keen to point out that good statistics have never been the true goal.

"We're really proud of the numbers and what the state has had to say, but in the grand scheme of things...our goal is to protect the community," says Waddell. "Whether it's somebody gets hurt in the street or a rancher from 27 miles out who comes to our facility, if they're in trouble, we think we have the capacity to help them and at least stabilize them and get them to a bigger center efficiently."

Waddell points out that a better indication of success for the team is that trauma patients often come back to the hospital for rehab. That tells the department that they are doing the right thing by the patients, he says, because otherwise they would prefer to go somewhere else.

"It's critical that we garner trust from the community and they feel comfortable coming here. There are critical access hospitals all across the country that are struggling and closing, quite frankly, because of either consolidations or lack of support from the local community," Shaulis says.

"We're very fortunate that the community here is supporting us by trusting us and coming to the clinic and emergency department, seeking out providers within our system."