ED improves on already impressive wait times
QI method uncovers improvement opportunities
Before the implementation of a LEAN initiative in the ED at Good Samaritan Hospital in Kearney, NE, the average door-to-doc time was 28 minutes, and the average length of stay was 103 minutes — numbers that were nothing to sneeze at. Nonetheless, Paul O'Connell, RN, director of emergency services, wanted to see those numbers improve.
"One of our biggest challenges was that we were at capacity for our volume [about 15,000 patients a year] for the number of beds we had," O'Connell explains. "We used one bed in a trauma room, one in an ENT room, so we were really down to eight beds."
The only answer was to improve efficiency, he reasoned. Patient surveys told him that the most meaningful thing to them was seeing the physician. "So we wanted to further reduce door-to-doc time and with that, hopefully, get an improved length of stay, so we could free up beds for the next patient who might be waiting," says O'Connell.
And reduce it they did. Since October 2008, 70% of ED patients are being seen in under 16 minutes, and length of stay is down to 93 minutes. In addition, less than 1% of patients are leaving before treatment.
In addition, by creating a central supply room, the nurses' average miles walked per shift was reduced from 8 miles to 11 miles to 3 miles to 6 miles. This was considered an important goal because the number of Good Samaritan's RNs over 45 years old had grown from 39.2% to 40.3% from August 2008 to August 2009, and the hospital wanted to retain these "wisdom" workers.
Camil Saadi, the process improvement specialist who oversaw the initiative, says that with the centralized supply room, "the nurse could go to the central area and do one prep." Saadi had measured how far the nurses traveled to get supplies and remeasured after the new supply room was established to determine the amount of improvement.
Here are some of the other changes implemented as a result of the LEAN initiative:
• Implementation of a patient tracking system.
This system gave all of the emergency services staff and ancillary staff the ability to communicate about the status of tests and timing. Physicians and nurses know which patients need to be seen; if the tests have been ordered, given, and verified; and if a patient is ready for discharge. The staff use a manual-entry whiteboard with magnetized color-coded symbols.
Saadi adds that the communication board eliminates wasted time because nurses and doctors are able to see everything happening with their patients in one location.
• Relocation of the communication specialist and the communication equipment.
These resources for the emergency service ambulances and helicopters were moved out of the central nurses station to the adjoining room where patients are registered. This move reduced the noise in the ED and allows the communication specialist to focus on the transport and patient information.
• Implementation of new physician and nursing documentation.
Provided by Dallas-based T-system, it was acquired in March 2009 to standardize the ED charting, simplify the charting for nurses, and decrease the amount of time required for documentation.
• The creation of standardized bedside carts and procedure carts.
With the bedside carts, nurses have the regularly used supplies they need right next to them, and the cupboards that took up valuable space were removed. The procedure carts are always stocked and can be pulled into any room as needed. These carts eliminated the need to have specialty rooms. The ENT chair was replaced with a chair/bed, which allowed this room to be used for more patients.
"Standardizing the rooms made everything so much more uniform, so wherever patients needed to go, everything would look the same to the staff," says O'Connell. "Before, we would get bottlenecks." The standardized laceration carts "could go anywhere," and the standardized supplies at bedside provided more resources at the point of care, he adds.
Staff drive changes in LEAN process
No one likes change, and ED managers often face a tough challenge when introducing new processes to their staff. This resistance was not the case, however, during a successful LEAN initiative at Good Samaritan Hospital in Kearney, NE, because of the very nature of LEAN methodology.
"The staff came up with the solutions — physicians, nurses, communications, the telemetry tech, the lab, radiology, even the switchboard," says Paul O'Connell, RN, director of emergency services. "The team drove the solution, not administration."
Camil Saadi, the process improvement specialist who oversaw the initiative, says, "The best part of LEAN is that you start with a blank sheet of paper and determine which areas you should focus on to give you the most benefits from an efficiency and capacity standpoint. A high percentage of patients we see in the ED are admitted, so that factored into why we chose the ED."
O'Connell made a significant contribution to the success of the initiative, Saadi adds. "It makes a big difference how well the director is involved and willing to put in the effort needed," he explains. "They have to be willing to think about the challenges the department faces, accept that there may be a better way of doing things, and be willing to work with the staff."
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