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Critical Path Network
ED's turnaround time cut by almost 30 minutes
Process 'pulls' patients out of waiting area
By implementing a Lean process change that it calls TAPP (Team Assessment Pull Process), the ED leadership in the Children's Healthcare of Atlanta system has realized a 25-minute reduction in median overall turnaround time, from 192 minutes to 167 minutes, excluding its fast track. The ED also achieved a 16-minute median improvement in door-to-provider time, from 44 minutes to 28 minutes, at its Scottish Rite campus. In addition, median length of stay has dropped from 136.5 minutes to 122 minutes.
TAPP works like this: The patients are greeted in the waiting room by a patient access greeter. A registered nurse is sitting next to the greeter from 9 a.m. to 3 a.m. They are then assigned an acuity level by the triage nurse. "From there, they show up on our [ED automation software program] board as a patient in the waiting room," explains Cresta Pollard, RN, BSN, assistant nurse manager. "Then, when a doctor is ready for a patient, they put their name as well as their communication number on the board."
The nurse will do the same, she explains. Once a second team member has signed up, they will call the first via the facility's internal phone system (ASCOM) and say he or she is ready for the patient. The nurse or a tech then will get the patient and tell the doctor what room they are going to. The doctor will meet the nurse in the room, where they will obtain a history, conduct a physical exam, and communicate the plan of care. The nurse will carry out the orders.
Before this change, the work in the ED had been "scattered and frantic," says Pollard. "We would have three to four patients at a time and put them into rooms, but they could be waiting an hour or more for a doctor; you might have orders on all four working at the same time, start with one patient, then go to another, and by the time you got to the last one, it could be an hour before it was all done."
Jennifer Berdis, RN, BSN, manager of clinical operations, says, "The nurses actually had to make decisions about what patient was a priority, while every doctor felt their patient was a priority, so the nurse was stuck in the middle. Now they do not have to make that decision because they are only working with one patient until they are done with orders."
The "pull process" refers to the fact that each patient is pulled by the nurse into the pod, or treatment area, where they meet their team. There are three pods in the department (including fast track), each with 17 rooms. The number of pods that are open and the number of team members varies according to the census. At full census (3 p.m.), there are approximately six nurses and three physicians per pod.
James Beiter, MD, the medical director, says, "The intention was to have the physicians stay within a team and a pod, but because we will open and close certain areas in the ED, it's hard to keep us in one area; we go where help is needed. It has not been as strict as it has with the nurses."