Patient navigators show the way to faster flow

Phone liaison position expands to different ED areas

The ED at Lutheran Medical Center (LMC) in Brooklyn, NY, has reduced its average door-to-doc time from more than two hours to 30 minutes in just 18 months, with the nearly simultaneous implementation of six major initiatives. The most innovative of all of the initiatives was the creation of a "patient navigator" position, originally conceived as a link between primary care physicians and ED physicians and nurses. The position later was expanded to include bed management and riding herd on test results and virtually any activity that could hinder patient flow.

"Our CEO and I had done this previously at another hospital, where the individuals were called communication nurses," says Claudia Caine, LMC's chief operating officer. The three full-time navigators at LMC are physician assistants. They cover two consecutive shifts each day, while a third backup navigator works in the quick care area, which was created as another one of the six initiatives.

The other four initiatives are:

  • electronic medical records and bedside registration;
  • ED huddle/inpatient huddle. Representatives from every discipline and patient unit meet in the ED at 11 a.m. each day to plan the day's strategy with Caine;
  • ED diplomat program. Senior staff members complete hourly rounds. They speak to patients and family members to ensure that they are comfortable and receiving all the services they need in a timely fashion;
  • ED greeter. A staff member meets and greets every patient who walks into the ED.

Navigating the ED

To perform their initial role, the patient navigators were provided with a separate telephone line. The primary care physicians, and some nursing homes, were given the direct numbers. "We tried not to give it out to too many people," says Caine.

Initially, this was done to ensure that private docs who sent in emergencies knew they would not lose their patients in a "black hole," explains Bonnie Simmons, DO, FACEP, chair of emergency medicine and medical director of pre-hospital care. Because ED physicians often didn't have enough time to interact with the primary care physicians and provide them with the updates they needed, "the navigators could be a liaison for them," she says.

This service was valuable not only to the primary care physicians, but for the ED physicians as well, notes Caine. "This may have been the single most important thing we've done for our doctors," she says. "Even as visits went way up, they felt they had a sense of control."

And go up they did, from about 137 patients a day to 167, which was part of the reason the position expanded. The other impetus came from the aforementioned 11 a.m. bed huddles. "The huddles existed before I came here, but we were not getting dramatic results," says Caine, who decided to attend every huddle personally. "The purpose of a bed huddle is to support the ED," she notes, and that just wasn't happening.

"I started to go at first just to watch, but I'm told things became different," says Caine. "The staff started to be much more aggressive about things like putting patients in the hallways upstairs." New ideas were instituted in a rapid-cycle fashion; after a few days, they would be discussed and evaluated in the huddle.

One of those ideas involved having the navigators attend the huddle. They still worked their central phone number, says Helen Costello, RN, the ED nurse manager. "But as we expanded our bed flow teams and the 11 a.m. huddle, and our bosses embraced the overcrowding issue, they started going to the huddle, she says. They would find out which beds were to become available and make sure admitting knew the ED's exact needs," Costello says. "Now, as soon as a bed is available, admitting calls them, they go to the nurse that has that patient, and puts the information on the tracking board." They also help expedite the transfer, close out the chart, or sometimes bring the patient upstairs, she adds.

If lab tests take too long, Costello says, the navigators will interface with radiology to get the results as quickly as possible. They also will help with family problems, such as long waiting times or ordering snacks.

The position clearly has become more formalized. "They start the day by looking at a printout of the tracking board and make rounds of all three ED areas [waiting room, quick care, and acute care]," Costello says. "They make sure all dispositions make sense, and if not, they will go to the doctors."

This position has morphed into a real navigator role, Simmons says. "It's expanded to anything and everything that has to do with patient flow and helping all our physicians and nurses with communication and moving patients through the system," she says. "I don't know how we ever lived without them."

Sources

For more information on patient navigators, contact:

  • Claudia Caine, Chief Operating Officer, Lutheran Medical Center, Brooklyn, NY. Phone: (212) 861-5122.
  • Helen Costello, RN, Nurse Manager, Emergency Department; Bonnie Simmons, DO, FACEP, Chair of Emergency Medicine, Medical Director of Pre-Hospital Care, Lutheran Medical Center, Brooklyn, NY. Phone: (718) 630-8383.