Matching nurses, skill sets spells ED success

Triage staffed by nurses with experience, interest

Although EDstat, a new eight-bed area that was added to the ED at Reston (VA) Hospital Center about a year ago, is only open from 11 a.m. to 11 p.m., it has helped to improve the performance of the entire ED. For example, in early spring 2007, before the new area opened, the percentage of patients who left the ED before treatment ranged from 2%-2.5% (statistics were measured monthly). Today, that has been reduced to 0.3%-0.4%.

In addition, time from arrival to triage was 18.59 minutes before EDstat, and 5.17 minutes after implementation. Door-to-doc time was 56.89 minutes prior to EDstat, and 34.07 minutes following implementation.

These results come as no surprise to Sherry Hawkins, RN, quality improvement coordinator for the ED. They've increased the number of beds from 22 to 30, Hawkins says. "We see everyone immediately, and treatment is started quickly," Hawkins says. "They get right to that bed. It's almost like an assembly line."

While the ED leaders credit much of the improvement to the superior processes the EDstat has brought, they also point to the staff as a key component of its success. That staff, they point out, not only possessed a specific set of skills that were needed, but they also actively expressed the desire to work in the new section. Although the department still has a triage area, the triage nurse's primary job is now to do a rapid-fire sorting of patients, immediately placing them on a bed in the EDstat area or the main ED. Patients with conditions that quickly can be cared for, such as minor lacerations, orthopedic injuries, and uncomplicated respiratory and gastrointestinal complaints, are sent to the EDstat area.

As the EDstat plan was taking shape, the managers of the ED recognized that nurses would require a very specific skill set to be qualified to work there. It's an area that requires a significant amount of focus and attention, says Kendra Cline, MSN, assistant director of the ED and ED educator. "You have to have excellent assessment skills so the patients can move quickly," she says.

This is the raison d'etre of the EDstat. Any patient that presents and does not need immediate intervention can be rapidly triaged and taken there. The triage process involves the chief complaint, a very brief history, the reason the patient came to the ED, "and what they look like, just enough information to know what their acuity level might be," Hawkins says.

When you are able to put more experienced nurses, who are a little quicker, there, the process works better," she says. "A lot of it also has to do with organizational skills, as far as determining who needs to be seen and what needs to be done next."

Cline says, "They also have to be adept at determining which patients need to be moved to the main ED, to free up beds in EDstat. Their technical skills need to be pretty superb, too, to get things, [such as starting IVs,] done quickly and efficiently."

Although there is a technician to handle splints and other basic services, "there is only one tech and two nurses, and they have to all be very proficient and also work well as a team," says Cline. The EDstat also includes a physician.

In fact, says Cline, the ability to work well as a team "may even be more important than their technical ability."

How did ED management evaluate that ability? "It's based on knowing your employees," she says. "If they function well together, it's something you see in their day-to-day practice. In fact, some people requested to go to the EDstat and work there together."

Wanting to work in the EDstat was another important consideration in the selection process, says Cline. Initially, the concept was piloted by Cline, Hawkins, and Teresa Kreider, MSN, RN, the ED director, says Cline. "We did it over a three-day weekend just to see how well we could make it work," she says. Next, they piloted the concept for six weeks using staff who told them they were interested in working within that environment, Cline says. "We are blessed to have experienced nurses, and there were quite a few who could do it."