Pit Crews and the EM Team

Have you ever seen a Nascar pit crew in action? They are a fine tuned team with well defined rolls, focused on their goal of changing 4 tires and delivering gasoline as rapidly as possible in order to get the vehicle back into the race. It is an impressive performance, and so short that a typical person observing will miss all the coordination involved. 

This link shows a video of a typical crew in action. It is 38 seconds long because it shows the same pit stop twice, from two different camera angles. My favorite part starts at the 27 second mark. Watch closely and you will see that the tires on the passenger side, nearest the track, are changed and then a quick but very orchestrated movement occurs:

1. The person fueling the vehicle takes a large step backward and waits. 
2. The rear person with the drill crosses in front of the man with the fuel. 
3. Meanwhile, everyone else crosses to the other side of the vehicle by going around the front. 
4. The man fueling the vehicle returns to filling the tank and helps his colleague by pushing the old tire out of the way with his left foot while another colleague brings in a new tire. 

This moment takes 5 seconds, and it is performed perfectly. A couple of questions might come up when you watch. For example: Why does one person cross in front of the man fueling the vehicle when they all swap sides? Why interrupt fueling at all? And if you have to interrupt fueling, why not have the two man tire changing team cross together instead of just the guy with the drill? The answers may not be as obvious. The man with the drill is tethered by a cable.If he crossed around the front of the vehicle, his cable would likely become trapped under a tire. Could the cable be thrown over the vehicle instead? Sure, but that would then catch the can at the top of the fueling rod. So, this person has to cross from the back. The rear tire man, responsible for carrying in the new tire and taking away the old, doesn’t cross along the back or interrupt fueling. But the slight delay in having him cross the front of the car leaves the drill man without someone to help remove the next tire. Here is where the fueler uses his left foot to help push away the old tire as the new tire is run back into position. Check out this team work in the clip. It sounds complicated, but it’s a 5 second move and I love it!

Now imagine you are on this team. Instead of one vehicle, there are 4 you are going to crew. You have a perfectly orchestrated workflow, so best solution would be to space all 4 vehicles apart with enough time to renew your supplies. No problem. 

Now imagine you have 4 crews but only one refueler, and multiple vehicles waiting. 8 vehicles pull in and teams split. The 4 drill men each take on one vehicle each. The tire men run back and forth grabbing old tires and bringing new ones but can’t catch up so the drill men assist by carrying some tires themselves. Meanwhile, the refueler starts with the first car and works his way back. What has just happened to our team? They have been fractured by the increase in demand and their efficiency is lost. Although each vehicle is having “something” done, no vehicle is actually receiving optimal service. 

So why are we talking about this? Because this is the model for how most emergency departments operate today. We have teams of techs, nurses, and physicians. Teams have an optimal balance and work best when they approach the patient together and develop a rapid care plan then take action. But increased demand leads to team fracture. We split teams, we split roles, and we physically separate team members further reducing their ability to communicate. In addition, as hospital crowding increases, and inpatient boarding increases, the remaining treatment spaces are no longer close together. Let me explain.

A large ED might have multiple pods which were designed to keep team members close to each other. Each pod has 10-12 beds and three teams with one physician. This would be the equivalent of having three nascar pit crews work three areas, side by side, while sharing one director. However, as admitted patients (borders waiting for beds) take up room, the team is fractured. Nurses remain in proximity to their patients (some of them boarders), but physicians are now forced to move between pods. Why is this a problem? Certainly she/he CAN move from one area to another, but this not only reduces their productivity, but it also removes the physician from the immediate vicinity and further destroys any attempt at team care. Running three pit crews on opposite sides of the track reduces the team’s ability to communicate and coordinate. Ideally, there is one pit crew per area. Less ideal is sharing members between two adjacent pit areas. Least ideal is splitting team members between multiple pit areas which are not near each other. There is increased waste in carrying supplies from one place to another, less opportunity for team work and communication, and more time wasted in physical movement. 

In the last decade, success has been achieved in moving care to non-traditional spaces, like triage rooms or converted sections of the waiting room. As emergency department beds are consumed by inpatients, ideally departments utilize inpatient nurses to care for them. This frees the emergency department team to do what it is trained to do: rapid assessment and delivery of care to a patient with an undifferentiated illness. “Teams” are recreated and placed in triage, waiting rooms or even sections of hallway. These teams are asked to change their workflow by providing care in a new area, with no stretchers but with chairs instead. However, the teams are geographically tied together so that steps are reduced, unnecessary delays are removed and the entire team workflow (instead of just one person) is maximized. It is the healthcare equivalent of a pit crew, and it works extremely well. Instead of disjointed and separate evaluations of patients, the entire team progresses through the care of a patient and understands the treatment and disposition plan. 

In this model, patients move instead of the team. Traditionally, patients stayed in a bed or in a single room while services were brought to them (bring the pit crew to the car), but reversing the process has great value. Not only does it reduce waste in movement of the team, but it keeps the patient moving instead of laying still and waiting. The vehicle is moving relative to the team. 

So you are probably asking “if this works so well, why isn’t everyone doing it ?” There are a few reasons: 

• Increased costs of staffing : Though this is ultimately recovered in improved productivity, many hospitals have difficulty understanding the need for additional nursing staff. 
• Finding staff: This is difficult for all institutions because of the national nursing shortage, but particularly hard for hospitals in smaller cities or less desirable locations. 
• Workflow re-design: This can be very costly if consultants are required, though they really aren’t. Staff are aware of what supplies they need regularly and what should be kept close by. They simply need permission to move things around and some assistance with developing simple restocking solutions (Lean process is one example).

Change is difficult, for all involved. At a time when most hospitals struggle with capacity, real solutions can seem elusive. Paying attention to staff workflow and restoring the team dynamics will go a long way in improving patient flow without requiring addition of more, traditional emergency department bed space. Though we are not working on vehicles, there is much we can learn from the process engineering of a nascar pit crew.