Nurses and registrars cut barriers to ED patient flow

New discharge process provides closure

Teamwork between clinicians and registrars has streamlined the emergency department (ED) operation at Wake Forest University Baptist Medical Center, in Winston-Salem, NC, resulting in shorter wait times, increased self-pay collection, and a more positive discharge experience for patients, says Keith Weatherman, CAM, associate director of patient finance.

What’s most impressive about the improvements is that they were accomplished without adding staff, notes Weatherman, who gives much of the credit to Charlynne Lynch, manager of ED registration.

When a consulting group identified various barriers to a smooth patient flow in the ED, Lynch says, she focused on "the only thing under my control — registration. My goal was to eliminate any barriers that registration caused."

One of the problems identified, notes Weatherman, was a delay between triage and registration. "Instead of taking the patient straight to [a treatment room], the patient might wait too long in triage for the registration to be completed."

With that in mind, Lynch says, she decentralized the process by putting registrars in the ED treatment areas — including fast track, pediatrics, and adult acute care.

Other enhancements to the ED operation include the practice of having nurses escort patients to the central registration area for discharge, and a new emphasis on collecting on self-pay accounts, while remaining compliant with Emergency Medical Treatment and Active Labor Act regulations.

Before, Lynch notes, patients often were told by clinicians that they could leave, with no real closure to the visit provided. "We would have patients who came back through registration and said, What should I do?’ Technically, we could have a trauma patient come through and then be able to leave [and have registrars] never even finish getting the demographic information."

Under the new procedure, Weatherman points out, staff are able to update the registration as the patient is being discharged. "By that time, the family may have shown up with insurance information."

The more consistent discharge procedure and increased focus on collections, which began Feb. 4, paid off quickly, he adds. During the month of March, staff identified insurance coverage for $101,000 in charges that otherwise would have been designated "self-pay," Weatherman says.

Cash collections for the months of February, March, and April totaled just more than $75,000, he adds, compared to just $2,000 for the last three months of 2001.

How it works

As always has been the case, emergent patients are directly taken to the treatment area, Lynch says. Under the new process, she adds, other ED patients also are taken to a treatment room if one is available when they are triaged. If the fast-track area is open — and the patient’s acuity level is low enough to qualify — the individual will be taken there, she adds. Registrars are positioned in all ED treatment areas to perform the registration at bedside, she notes.

"If a bed is not available, the patient stays in the waiting area," Lynch says. "We have personnel in central registration who will complete the registration." Under the new system, a patient who comes in with ankle pain, for example, might receive an X-ray during the wait, since he or she already is in the system, she adds.

The idea, Lynch says, is that the faster the patient information can be entered into the computer, the faster order entry can begin. "The way the ED is set up, [the patient needs] to be in the computer system for labs to be ordered."

With an acute patient, registrars might do an abbreviated registration, she notes, getting just enough information so that orders can be entered and a face sheet printed before the patient goes back for treatment.

Otherwise, a full registration will be done at bedside or in the waiting area. Registrars in the treatment areas use radio-frequency laptop computers, which the department already had on hand, she adds, so no capital outlay was required.

One of the problems with the old system, when there were no registrars in the treatment area, is that patients who arrived by ambulance were not being registered quickly enough, Lynch notes.

"We waited for nursing to put the patient’s name in the system, which alerted admitting that the patient was here," she says. "This was contingent on the nurse stopping what she was doing to type the name in."

Now that registrars are in the treatment area, Lynch adds, they can see the patient arrive and immediately start the registration.

Nursing plays big role

The support of the ED nurses has been crucial to the initiative’s success, Weatherman stresses. "What’s impressed me is the folks I’ve seen who have stepped out of the box and made it a team effort between clinical and registration."

Being escorted to the registration area after treatment conveys a sense of caring to patients, Lynch points out. "They’re not just left hanging. The nurse says, Follow me,’ and takes them to discharge. There’s a complete handoff, whether it’s by a nurse, nursing assistant, or maybe even a physician."

Once the clinician walks away, she notes, it seems the patient often has a question regarding treatment or follow-up. Personnel at the central registration desk ask if there are any final questions, Lynch adds, and if so, they call and inform the caregivers. "It gives the patient one more opportunity."

Lynch is heavily involved in the faculty meetings of the ED attending physicians and the nursing administration, she says, which has fostered the communication between the areas.

"We have a good working relationship," she notes. "They have given the space for our registrars to be back in the treatment area, and, in return, we gave them a registration booth to enable them to have a third triage area."

Although response to the new process has been overwhelmingly positive, Weatherman notes, there has been "some friction" when consulting physicians find themselves sharing space with registrars.

"It’s just a big change," he points out. "Staff are having to learn new roles, they have to walk more, go to the patients. It’s been a philosophical change."

All ED registrars received training to familiarize them with the new process, Lynch adds. "We laid the groundwork, told them what our vision was, what the things were that we could control, that we could change."

Teamwork among access staff is a key part of the process, she notes. A registrar in the pediatric area, for example, who may not have a patient to register, must be alert to needs in other areas, she says. Those who are busier, meanwhile, need to "pick up the phone and let somebody know they need help."

Challenges come when all the ED beds are full and everyone is waiting, Lynch adds. "Then we flex’ back into central registration. [Registrars] have to anticipate and think, What do I do in this situation?’ It takes a person who can multitask."

Lynch formulated guidelines for what each role in each area would be and a follow-up plan with measurable goals. The monthly goal for registration accuracy, for example, is 96%. The number of consent forms signed compared to patients seen is another measurement, she says.

Patient satisfaction with ED registration, as measured by Press Ganey Associates surveys, jumped 3% following institution of the new ED procedures, Weatherman notes. The hospital did well across the board on the survey, he adds, receiving the No. 1 rating among all facilities using the Press Ganey measurement tool.

To glean feedback from staff, Lynch says, she had each person fill out a survey, and then the supervisors individually met with staff members to discuss their comments. "Some aren’t happy, others are delighted," she notes. "A lot of it has settled down in the past few weeks."

Concerns expressed in the staff survey were categorized and will be followed up on, Weatherman adds. "We let [staff] know we want to listen and do whatever we can to correct any problems."

Although she formally has yet to survey the ED nurses, Lynch says she receives positive feedback from them. "I’ve had nurses stop me and say they really enjoy working with the registration clerks. In one case, a nurse saw a conflict beginning and nipped it in the bud. She stood up for registration."

[For more information, contact:

Keith Weatherman, CAM, associate director of patient finance, Wake Forest University Baptist Medical Center, Winston-Salem, NC. Telephone: (336) 713-4748. E-mail:]