Mobile unit helps ED cut LWBS in half

Ultimate goal: Reduce turnaround to 90 minutes

The ED at Jefferson Memorial Hospital in Ranson, WV, has reduced its rate of patients who leave without being seen (LWBS) by 50% with the addition of a mobile unit located immediately outside the main department.

The unit is staffed by a registered nurse, a nurse practitioner, and a technician who floats between the new unit and the main department. An ED physician is available to consult as needed. The unit was badly needed, managers say.

"About a year ago, we looked at our volume and capacity and it became painfully apparent there was no way with this footprint [the size of the main department] that we could support the process changes needed to meet our goal, which was to turn our door-to-discharge time around," recalls Tina Coad, RN, MSN, MSM, CEN, FACHE(d), the ED nurse who instituted the addition of the unit, which has four treatment rooms. The American Institute of Architecture (AIA) recommends 1,500 to 1,800 visits per bed, she says. "We had eight beds and were up to 22,000 visits a year," she says.

The mobile care unit also is equipped with computers, a medication dispensing system, and monitors to view digital X-rays.

Another key goal was to achieve a 75- to 90-minute average door-to-discharge time for nonemergent patients. Denise Carter, RN, BSN, the ED nurse manager, says, "Sometimes, it was as long as two to three hours just to get into a bed."

Realizing the seriousness of the situation, Carter and Coad "went to the drawing boards to determine what we could do to create additional space for the ebbs and flows of patients that was not too painful, not too expensive, and would give us immediate relief," says Coad. "I had worked with mobile care units in the past, so we went and found one that could be easily mocked up to be an ED care unit."

The unit, which is leased from Baltimore-based William Scotsman, costs $200-$300 per month.

Was it difficult to convince administration to make the investment? "It was a no-brainer — the easiest sell ever," she says. "If you just did the math you could see we were grossly underbedded. In the whole scheme of things it was not that expensive, and we could set it up right outside the [ED] door."

Basically, the mobile unit serves as a fast-track facility. The ED's previous internal fast-track was anything but that, managers say. "With those eight beds we had, when more serious patients came in they got the bed, and the fast-track patients had to wait," Carter explains. It was a double-edged sword, Coad says. "The fast-track area became the exact opposite," she says.

Now, when patients present in the main ED, they are seen by a triage nurse. Based on "very tight criteria" established cooperatively by the ED physicians, nurses, and nurse practitioners, the triage nurse determines whether they should go to the mobile care unit, Coad explains. Carter adds, "Even if they do, whatever testing can be done first — like X-rays, urinalysis, or strep cultures — is done [in the triage area], and they are then escorted to the mobile unit by the nurse and treatment is finished over there."

Although the mobile unit has been in use since August 2007, it is not yet possible to obtain "clean, scrubbed data" on just how much time it has saved, says Coad. There have been other infrastructure changes during that period. Also, they added a new ED physician leadership team recently and experienced some staffing challenges with nurse practitioner coverage for a short time, she explains.

In addition, says Carter, the hours of operation for the new unit were changed on Jan. 1. "At first, it was open from 11 a.m. to 11 p.m., but now we've started to have hours from 1 p.m. to 11 p.m.," she says. The times were changed due to the staffing changes, Carter says.

"We do know that we decreased walkouts, and that was our biggest problem," she says. Before the mobile unit was installed, the average rate reached 10%-12% in some months, Carter says.

Patients are very happy with the new mobile unit, says Carter, "and the staff loves it, too. It decompresses their patient bottlenecking." It was not necessary to add staff to run the mobile unit, she says. Instead, their time schedules were revamped to accommodate needs when the unit was open.

More help is on the way for the Jefferson Memorial ED. Earlier this year, a certificate of need to expand and renovate the existing ED was approved by the West Virginia Health Care Authority. The $4.6 million project includes a 5,000-square-foot expansion of Jefferson Memorial's existing ED from eight to 19 beds, additional parking, renovations to the waiting rooms, and the addition of a decontamination room.

Carter says the ED is planning on keeping the unit. "We will be going through a great deal of change with the construction process and will be using the mobile care unit to decompress some of those changes," she explains.

Source/Resource

For more information on converting a mobile unit into additional ED space, contact:

  • Denise Carter, RN, BSN, ED Nurse Manager, Jefferson Memorial Hospital, Ranson, WV. Phone: (304) 728-1701. E-mail: dcarter@jeffmem.com.

For more information on buying or leasing mobile units, contact: William Scotsman, Baltimore. Phone: (800) 782-1500. Web: www.willscot.com.