Use latest technology, creative thinking to tackle challenges of ED overcrowding

Tracking system, good use of data provide answers at Wake Forest

With a recent study highlighting the lack of surge capacity in the nation's emergency departments (EDs) and concerns about how health care facilities would respond in the event of pandemic flu, it's imperative that hospitals find meaningful patient throughput solutions, says James Bryant, director of emergency and transport services at Wake Forest University Baptist Medical Center in Winston-Salem, NC.

The American College of Emergency Physicians' (ACEP) "National Report Card on the State of Emergency Medicine," which gave the emergency medicine system of the United States as a whole a grade of C minus, was "a wake-up call for the national health system," Bryant adds. "This is a challenge to make our system more flexible."

At least part of the response to that challenge lies in technological innovations, such as ED tracking systems that identify where patients are in the process and where the bottlenecks are, he says. With hospitals that have such systems, Bryant notes, the question becomes, "How are they using those data?"

Wake Forest put an electronic tracking system in its ED two years ago and began to see, among other things, that patients who had been triaged were sitting in the waiting room even though there were empty beds in the treatment area, he says.

"If there is a ready bed, patients should move directly from triage to the ready bed," Bryant says. "Putting them in the waiting room for 10 minutes just causes delay. That was the way we'd always done it, but it's not a good model. If you've got a bed, put the patient in it."

With the tracking system, everyone on staff sees the same information, he says. In the past, Bryant adds, the triage nurse might not have known what was happening in the back, and the charge nurse might have been unaware of the situation in the waiting room.

"If I don't know there are 15 people waiting to be seen, I may not be in as much of a hurry," he points out. On the other hand, if the charge nurse is aware of that crunch, and sees that a person is waiting for discharge, Bryant notes, "she realizes that if she just goes over and [discharges the patient], she could have a ready bed."

Even newer technology — now in place at only a handful of facilities — would allow hospital staff to place transmitters on patients and look at a screen and know exactly how they're moving through the department, he says.

The process is the same as that used by the retail industry to create automatic inventory tags, Bryant notes. "Price is still prohibitive, but we're looking at the technology."

Patients wearing these radio frequency identification (RFID) bracelets, he adds, can be greeted by name, for example, as they approach the imaging area: "Hello, Mrs. Jones. We were expecting you."

"Bar codes are really popular, and this is the next evolution of bar codes," Bryant says. "Patients would still get a bar-coded armband, but they would also have an RFID band."

In terms of patient safety, he adds, there would also be RFID tags on blood and medication, so that any mix-ups would be flagged.

Diversions 'a symptom'

The ACEP report points out in its listing of national emergency care concerns that only 10 states currently collect data on the frequency with which hospitals go on diversion status, or "divert" ambulances, because they are unable to handle any additional emergency patients.

While diversion information is "very important," Bryant says, "hospitals are starting to catch on that if hospital A goes on diversion, hospital B almost has to go on diversion, and so on; it just shifts the burden."

Wake Forest has a "no diversion" policy, he adds, partly because it is a level one trauma center.

"Each hospital has to learn how to respond to its surge," Bryant says. "Diversion is a symptom of the problem." The report, he says, makes note of the need for surge capacity in the critical time between when a disaster occurs and when state or federal resources can be mobilized to respond. That need was highlighted by the Hurricane Katrina disaster.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has recognized the situation as "more than just an ED problem," Bryant notes, and has instituted standards requiring hospitals to have a plan in place to address patient flow.

At Wake Forest, where an ED designed for 56,000 visits a year is accommodating 76,000, Bryant says, an ED holding unit is helping facilitate patient flow.

"Part of the rationale is that many patients are here for several hours just because of certain testing procedures; so we created a 10-bed holding unit on the sixth floor," he explains. "If patients are going to be [in the ED] for multiple hours, we move them there so we can bring in more acute patients."

The effort has been successful enough, Bryant notes. Plans are in place to expand the hours of the holding unit from 12 hours a day, six days a week to 24-7, probably in January 2007.

"It's been a real positive," he says. "It also offers more opportunities for the ED staff. If you're an ED nurse, the holding unit can be a little bit of a break. We can float staff, so it's a big staff satisfier."

'Quick reg' key to improvements

Innovations on the front end of Wake Forest's ED operations also have proved fruitful in enhancing patient flow, Bryant says. After patient satisfaction surveys showed that people were dissatisfied because they felt they were not acknowledged upon their arrival in the ED, the hospital took another cue from the retail business.

"We put in a patient greeter, who takes the patients' names [immediately] and puts them into the system, along with the complaints," he explains. "The triage nurse looks at the screen, sees the complaints, and takes the most urgent first.

"Initially our goal was for the patient to see the triage nurse within 15 minutes of arrival, but now we've gotten it down to four minutes or less," Bryant says. "We were able to use the data created by the greeter, which include how long the person has been waiting."

Again, those data also are seen by the charge nurse who — seeing that five people have come in at once — sends someone out to help, he adds.

Before the greeter position was created, notes Charlynne Lynch, CAM, manager for ED registration/financial counseling, patients checked in at the central registration desk before going back for treatment.

"[The greeter] has certainly expedited the process, because [patients] no longer have to wait on us," she says. "In the past, if the triage nurse was busy, there was no one there to greet the patient and no coordination at the front desk."

The patient greeter is in place around the clock, and reports to the nursing department, Lynch adds, although there has been some discussion of switching the position to the registration department.

The greeter, she says, goes into the admission/discharge/transfer (ADT) system and does a "quick registration," starting with a patient name search in which he or she enters the patient's last name, first name, and middle name, and asks to see a Social Security card or driver's license for identification.

If the search does not locate a medical record for the patient, Lynch notes, the greeter asks for the person's date of birth in order to create a new record.

Additional elements that may be entered during the "quick reg," she says, but don't have to be, are gender, race, mode of arrival, attending physician, and patient location, as well as ED, pediatric ED, or "fast track," a lower acuity area that is open from 11 a.m. to 11 p.m.

Registrars look at the registration later, after patient care has been initiated, and verify all the components, Lynch adds.

ED "quick reg," an innovation that came about around the same time the electronic tracking system was implemented, got its start when ED staff and leadership were looking at a way to get patients on the tracking board without having to wait on registration, she explains.

"There are only a few registrars [to go around], but we have nurses or other clinical staff who are with the patient pretty fast," Lynch says. "Even one of the physicians said we don't have to have a [registrar] to be there immediately at all the beds."

Although she personally wrestled with the idea of relinquishing control of this piece of the registration process to clinical staff, the results speak for themselves, Lynch says now. "It works."

She says she has been asked by access colleagues, "How comfortable are you giving that authority to nurses? Aren't you worried about duplicate medical record numbers?"

While she did have concerns about duplicates, Lynch explains, she was confident in the ED leadership's commitment to accuracy. "They also don't want any adverse effects. They've done an excellent job, and it's noticeable to us as staff members that the flow is much quicker.

"Now the patients are rapidly put in the system, so the information is captured as soon as they get there," she adds. "Even in the back, if the patient comes in by ambulance, the nurse does the quick registration. We gave [nurses] the capability to do what we used to do. Now they're not waiting on registration at all. We're not in that flow, although we are definitely the support system."

The medical records department worked with registration staff in training both nurses and unit secretaries to do the quick registration, Lynch notes. "We modified our Healthquest system, a McKesson product, to allow the search for a medical record number to happen on a 'quick reg,' and to include only the fields that concern the clinical staff.

"If the nurses do select a good medical record number, they don't have to go through the patient name fields," she adds. "[The system] will go straight to the fields they need to complete. It's not requiring them to do everything a registrar would do."

The one exception to the ED quick registration process is that trauma patients still are registered by her department, she notes. Registration typically receives a call in advance of a trauma patient's arrival, Lynch says; but even if a patient is already in the ED and then upgraded to trauma status, registrars are still notified and handle the registration.

"We have trauma packs with new medical record numbers," she adds. "We coordinate the trauma packs and we maintain a log for trauma registry. We want everything at the bedside when those patients arrive."

(Editor's note: James Bryant can be reached at jbbryant@wfubmc.edu. Charlynne Lynch can be reached at chlynch@wfubms.edu.)