ED's 'PALs' help put focus back on patients

Overcoming staff distractions from technology

At Parkview Medical Center in Pueblo, CO, the introduction of an electronic medical record (EMR) in 2004 was a mixed blessing, at best, for the ED. Patient flow was slowed dramatically, and patient complaints rose because the staff seemed to be paying more attention to the computer than to the human beings they were treating.

While the temptation was strong to simply stop using the technology, Mike Archuleta, RN, MSN, CCRN, director of emergency services, found an even better solution. He established a group of Physician Assistant Liaisons (PALs), second- and third-year nursing school interns, who were paired with each emergency physician to handle the data-entering functions.

"A red flag went up when we saw our LWOC [left without care] rate, which had been 0.8%, went up to 2.5%," Archuleta recalls. "The waiting room was backed up, and our customer service scores, which had been in the high 80s, dropped to the mid-80s." Pueblo uses surveys from Avatar International, of Lake Mary, FL. Prior to the change, Parkview had been designated a "Five-Star" facility by Avatar.

In addition, he says, ED length of stay, which had been averaging three hours, "was getting over four hours, and we had a lot more stays going six hours or longer."

Are such changes a natural offshoot of switching to EMRs? "They can be," Archuleta says. "A lot of EDs went through EMRs and then switched back to paper."

Since the EMR was a hospitalwide initiative, Archuleta looked for a way to attack the problems without getting rid of the EMR.

"When I started getting complaints that nurses and doctors were talking to the computer and not to patients, I brought it up at our regular Monday [staff] meeting to talk about possible improvements," he says. The other issue was that physicians were not keeping up with order entry at the bedside, Archuleta says. "Some physician orders were still being put on paper, and there was a lot of inconsistency," he says.

Initially, Archuleta suggested having a unit clerk or secretary work with the physicians or using some of the emergency medical technicians (EMTs) and paramedics to perform order entry, start an IV, or perform an EKG. A pilot program was started. "But they weren't quite the right match," he concedes. "They were unfamiliar, for example, with the names of life-sustaining meds such as antibiotics."

Archuleta then hit upon a solution: nursing students. "I thought, why not use the interns?" he says. The hospital already had established nurse intern programs, run in conjunction with Colorado State University-Pueblo and Pueblo Community College. They already had knowledge of pharmacology, assessment, and medical terminology, Archuleta says.

The program was then piloted using the students, and it was "a dramatic success," he says. Brittney Romero, RN, a former PAL who is now a nurse in the ED, says, "We would do orders, assist the doctors with some of the procedures, do the charting, and enter labs. You would enter the room with the docs and sometimes explain to the patients what was going to happen."

An all-around win

Archuleta says the program was a benefit not only to the patients, but to the ED staff and the PALs as well. "The PALs had a 100% pass rate [on their nursing boards], and some eventually became nurses in the hospital," he notes. This also helped meet his desire to only use experienced nurses in the ED, he adds.

"The PALs learn the practices and preferences of the ED physicians, which helped establish good relationships between the nurses and the medical staff, where in the past there had been some friction," Archuleta says. "They really got to know one another." The interns also became much more informed nurses, learning about the flow of the ED and what doctors' orders could be anticipated, he says.

He believes the program also helped improve relationships among existing staff. "There had been a little controversy among the nursing staff about docs not sharing enough information with them, but we have a lot of nurses who also worked as PALs, and that helped close that gap," Archuleta says.

As for the program's impact on the ED, the LWOC rate was back down below 1% after less than six months. "Our customer service score has climbed up again," Archuleta adds. He says the scores now are between the 88th and 90th percentile, which puts Parkview among the top two Avatar-rated EDs for departments of comparable size.

The PAL program also is paying off in ED performance measures, he says. "On average, ED patients are being seen 15 minutes faster than they were before the program was introduced, and length of stay has crept back down to numbers seen previous to EMR implementation," Archuleta says. "Throughput has dramatically improved, with physicians seeing 0.5 patients more per hour, increasing to an average of 2.5 patients per hour since PAL was put into place with nursing interns."

In short, he concludes, "This is one of the best things we've ever done."


For more information on Physician Assistant Liaisons (PALs), contact:

  • Mike Archuleta, RN, MSN, CCRN, Director of Emergency Services; Brittney Romero, RN, Emergency Department, Parkview Medical Center, Pueblo, CO. Phone: (719) 584-4917.