Empowering staff creates ED throughput solutions

'Identify problem, suggest a change'

One of the most effective strategies for enhancing ED throughput at Wake Forest University Baptist Medical Center in Winston-Salem, NC, has been to create small working groups to address specific problems, says James Bryant, director of emergency and transport services.

"We identify the problem, suggest a change, and get a small group of staff members together to do a trial," he says. "We depend on them to tell us what works and what doesn't."

The reasoning, Bryant adds, is that "we work with very talented people, and we trust and expect them to do a good job. All we have to do is say, 'This is our goal and here are our resources.'"

An example of this theory of employee empowerment, he says, was a "door to balloon" project aimed at reducing the time it took to get a patient complaining of chest pains to the cardiac catheterization lab.

"We knew that the time it takes to get a patient with a suspected heart attack from the ED to the cardiac catheterization lab for an angioplasty was a [measurement] that was being monitored by the Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services."

In late 2004, when the project started, Wake Forest had an average "door to balloon" time of 180 minutes, Bryant notes, and set a goal of 120 minutes.

A team was assembled that included a registrar, a nurse, a nursing assistant, a member of ED administration, and an employee from the cath lab. After looking at the entire process and identifying the bottlenecks, he adds, the team developed a standardized procedure for such patients.

"[The team] came up with a checklist, standardized orders, and created a box with the special equipment needed for the cath lab," Bryant says. When a person complaining of chest pain presents at the ED, he adds, the patient is taken directly to an ED bed, along with that box, which also includes all the forms that will be needed.

Eventually the team was able to get the "door to balloon" time down to a low of 67 minutes, Bryant says. "It's been below 90 minutes for the past four months."

In the past, those patients might have seen a triage nurse, been placed in the waiting room for a few minutes, and then taken back to a bed, he adds. "Different people did it different ways, but all that added up to delays. We've eliminated that variability and we get people upstairs [for angioplasty] faster."

Before nurses were empowered to do quick registrations in the ED, notes Charlynne Lynch, CAM, manager for ED registration/financial counseling, clinicians had to wait for a registrar before certain treatment steps — such as ordering an electrocardiogram — were taken.

"It's not that [registration] prevented patients from being treated, but it was just [a matter of] at what point the medical record was generated," she says. During an earlier effort at facilitating the door to balloon process, Lynch adds, if the nurse knew she had a patient fitting those criteria, she had to call the registration department, provide the person's name and date of birth, and have someone run down the medical record number.

"The continuity of information wasn't as smooth," she says. "The [clinician] might have had to start the procedure without having the medical record number at that moment because it was left up to the registrar to get that piece."