A hospital in Mississippi has significantly improved its emergency department (ED) throughput and reduced the perennial problem of overcrowding in part by embracing a concept that most facilities try hard to avoid: treating patients in hallways and other non-standard areas.
In 2016, Forrest General Hospital in Hattiesburg, MS, was facing ED issues that are common to many facilities. Patients were dissatisfied about long wait times, the waiting rooms were filled on a regular basis, the hospital had to devote significant nursing resources to caring for patients in waiting areas, and a high number of patients left without being seen.
Staff also were unhappy about working conditions, and turnover was high. Hospital leaders decided to launch a comprehensive look at why the ED was not functioning well and change whatever processes needed improvement.
Forrest General’s ED is high acuity, serving as a referral center for most of southern Mississippi. The ED volume in 2016 was about 80,000 patients a year and has increased at least 5% every year since.
The metric that crystallized the problems in the ED was the rate of patients leaving without treatment (LWT), says John Nelson, MD, FACEP, medical director with the hospital. That figure was typically 6% or 7%, and some months it reached 8%. No one was happy with that figure because they knew it signified a range of throughput and patient satisfaction problems, Nelson says.
That figure now is about 2%, even though ED volume has increased 20% since the start of the project, he says.
Length of stay (LOS) in 2016, at an average 227 minutes for all patients (and almost 300 minutes for admitted patients), also was an issue, Nelson says. The time from arrival to putting a patient in a room was approaching 30 minutes. Patient satisfaction numbers were in the cellar.
“We reached a point where we knew something had to change,” Nelson says. “We didn’t know at first whether it would be manpower, the rooms available to us, or some other solution, but we knew those numbers were not sustainable. We had to address it in some way if we were going to continue this growth pattern.”
Assessing Current State First
The working team included ED medical directors, emergency medicine physicians, the ED patient care manager, project analysts, patient care coordinators, staff RNs, an ED technician, and a unit assistant. The hospital worked with quality improvement consulting firm Vizient, based in Irving, TX, to develop a solution.
“You have to have administration support on something like this, and we lobbied heavily to have the whole institution involved in addressing this problem,” Nelson says. “We worked hard to involve not just the ED, but inpatient nursing, trauma service, cardiology, radiology, lab, social services, registration, housekeeping — everyone. If we lose any of those people’s involvement, that creates a slowdown or a road block that can thwart everything else we’re doing to improve these processes.”
They began by assessing the current state of operations and collecting baseline data. Arrival patterns, which help to gauge volume per hour of the day and guide staffing decisions, were especially important. They also mapped current processes to eliminate waste, designed new processes, and then matched staffing to the new processes.
“I can tell you from the physician side that it can be hard to hold that mirror up and look at yourself honestly. We had to change the way we look at things and be more conducive to change,” Nelson says. “We were set in our ways and didn’t want to think about changes. It worked fine that way 20 years ago, so why shouldn’t it work now?”
It was not just physicians, though. Nurses and other staff also tended to make excuses for the high LWT and LOS rates, says ED nursing director Sheila Shappley, RN, BSN, MBA.
Three Key Influences
The team identified the three factors that limit patient flow: bed, doctor, and nurse. They also determined that clinical assessment must occur as soon as a patient arrives at the ED.
Forrest General found that a key to improving ED care was matching nurse and provider staffing to expected patient volumes. Overcrowding and slow throughput were not caused only by a lack of beds, they found. Any shortfall in beds, nurses, or physicians would create problems. One strategy was to increase staffing earlier in the day so there would be sufficient human resources when the patient volume began to increase.
This was different from the previous practice of bringing on additional staff at the time of expected increase, Nelson explains.
As the day went on, the hospital had more and more patients who left without treatment or were not seen in a timely manner, sometimes getting in a room and waiting a couple hours before providers were able to get to them, Nelson says.
“We had been adding more staff to the later shifts and at night because there were so many people coming in. But we found that if we front-load the day and have providers, nurses, and everyone else here early in the day to address that swell in patient volume as it comes in, then we didn’t have nearly the holdover into the midafternoon and into the night,” Nelson says.
“That made the nights more pleasant because we weren’t trying to catch up with all the patients who had come in earlier and were still waiting to be seen.”
The improvement team and others at the hospital initially resisted the idea, sticking with the philosophy that more staff should be added to the times showing the highest volume and worst metrics.
They had to be convinced that the growing backlog of patients throughout the day was a key contributor to those bad numbers for LWT and LOS in later shifts, Nelson says.
The goal is to stay ahead of any surge in volume by keeping patients moving through the ED and optimizing available beds, Shappley explains.
With the new systems in place, patients rarely wait in the lobby the way they used to. From 2016 to August of this year, the average time it took for a patient to be placed in a room after arrival decreased from 27 minutes to 13 minutes. Also during that period, average LOS for all patients decreased from 227 minutes to 211 minutes.
Changes to Work Schedules
The new processes required coordination and increased attention by managers to schedule changes and shifts. They had to ask nurses to change their normal shifts and sometimes to work extra hours. The changes were communicated to staff with a packet of information, process books placed in all patient care areas, and meetings with each shift team.
The process for handling emergency medical services (EMS) radio calls also needed improvement. The process at that time called for an RN to take the radio report and then call the triage nurse for a bed assignment. The triage nurse would then assign a bed to the EMS patient in the hospital’s system.
Under the new process, the RN who takes the radio calls assigns the bed, saving time and decreasing the workload for the triage nurse.
Forrest General also implemented a new two-stage triage process. The new process is intended to identify and immediately route patients who do not require full triage assessment.
“Previously, we had a one-step triage in which everybody waited in line at one window. Now we have a multi-step triage system so that if you have a minor complaint, you are sent to the minor treatment area right away, and if you have a critical need, you go straight to the critical care area of our ED,” Nelson explains.
“Those in-between patients with complicated medical issues are fully evaluated at a second station and given rooms from there. Our mantra has been that if at all possible, everyone goes to a room, and nobody goes to the waiting room.”
The average time from arrival to triage has gone from 13 minutes to two minutes, Shappley says.
The new system aims to eliminate placement of patients in inappropriate care zones, minimizing the placement of very sick patients with less sick patients whenever possible. Behavioral health patients also are placed in designated rooms.
Nurses Swarm Patients
Forrest General implemented a team care model they call the Swarm Approach, in which two RNs attend to the patient as soon as he or she is placed in the room. They each have specific duties. The primary nurse is the one who was assigned to that room at shift change or midshift and remains the primary caregiver for that patient throughout the stay. A support nurse helps the primary nurse.
The primary nurse introduces the rest of the care team, explains to the patient what to expect during the stay, and queries the patient about the chief complaint and other vital information. This nurse also collaborates with the support nurse and manages order protocols and sample collection. At the appropriate time, the primary nurse checks the bed board for the next patient.
The support nurse gowns the patient, preps supplies, and performs the initial physical assessment, verbally communicating those findings to the primary nurse. This nurse also initiates IV lines, collects specimens, applies specimen labels, and delivers specimens for testing.
Hallway Spaces Add Capacity
As part of the ED process overhaul, the hospital was able to increase the number of beds available to ED patients. The ED had 50 beds in operation previously and increased that to 55. But it also designated 28 “virtual spaces” — eight stretchers and 20 chairs in hallways and nearby seating areas. That makes a total of 83 potential patient spaces available for ED care.
The hospital also divvied up the available ED space in a more strategic way. Previously, there was a critical care area and the rest of the ED. Now there is a critical care area, an area for complicated medical issues (but not critical ones), two other areas for less complicated medical issues, and a minor care area. Each is staffed differently, with providers and staff appropriate to those levels of need.
“The nurse practitioners are much more productive with the new treatment areas, even though I would have thought we might see a backup with the new system,” Shappley says. “We are very protective of not mixing up our acuities, because then you get less production out of everyone.”
Physicians at first resisted the idea of being assigned to the specific care zones rather than seeing the next patient no matter what the acuity, Nelson says.
They soon warmed to the idea of staying within one smaller area of the ED for their shifts. “With 47,000 square feet in the ED, it was not usual to be with one patient and then the next patient is on the other end, which is 100 yards away,” Nelson says. “This lessened our footwork and the nurses know who to go to to communicate about certain patients. This improved our efficiency and the length of stay.”
The addition of the virtual spaces — essentially designated hallway locations — helped the ED deal with the waxing and waning of volume throughout the day, Nelson says.
The ideal is still for patients to remain in an exam room when possible; but when volume dictates, they can be moved to a virtual space if, for instance, they are stabilized and simply awaiting test results.
“Our busy days typically are Sundays and Mondays, but our busiest day in the last five years was a Thursday. Sometimes data doesn’t tell you everything and you can’t predict when you’re going to have an extremely busy day,” Nelson says. “So, the virtual spaces allow us to flex with that and manage the high days and low days — and the high and low times within those days.”
Hallway Idea Not Easy for Some
Shappley and Nelson say accepting the idea of placing patients in the hallways was a huge change in thinking for everyone at the hospital. Like at most hospitals, “boarding” patients in the hallway is frowned upon as a last resort, something to be avoided if possible.
The practice was seen as a sign of failure for the ED, or at least a sign that it was hopelessly overwhelmed by patient volume, she says. And it was generally assumed that patients did not want to be put in the hallway, seeing it as demeaning.
The proposal for actively using the virtual spaces met with a lot of resistance from both staff and administration. The turning point came when the hospital asked patients how they felt about the idea.
“We found that as long we can protect their privacy and their dignity, patients were much more amenable to being in the hallway if that meant they were being taken care of and the next time they came they wouldn’t be waiting in the lobby,” Nelson says.
“Previously we were kind of embarrassed they were out there, so we didn’t want to talk to them, and they didn’t want to talk to us. Now it’s very different. We stop to chat and make sure they have what they need, and we see it as a positive indicator that they’re being taken care of.”
Physicians who initially resisted the idea are now on board because they realize that it allows them to see more patients, Nelson says. He sometimes gets calls from doctors asking that more patients be moved to the hallways.
Protocol for Hallway Use
Patients are not simply shuffled off to a virtual bed space when the ED is busy. There is a protocol to follow, which starts with making sure the initial nurse swarm and treatment are completed and that all portable imaging exams, if ordered, are complete.
The patient also must have had the first contact with a physician, and any patient requiring a cardiac monitor or continuous supplemental oxygen as part of the ED care must remain in a room rather than going to a virtual care space. However, a patient who uses oxygen daily can be moved to a virtual space.
The primary nurse decides whether the patient meets the criteria for a virtual bed and transfers the patient to a hallway care space when appropriate.
When moving a patient to a hallway space, the primary nurse first explains the situation to the patient and draws from this script developed by the hospital: “Our ED is beginning to get full and our goal is for every patient checking into the ED to be immediately placed in an exam room to be evaluated by a provider and nurse instead of having to be placed in the waiting room until an exam room becomes available. Since you have been evaluated by a provider and a nurse, is it OK for us to move you to a hall bed/chair while you wait for your disposition so we can make this room available for the next emergency patient? We certainly will take very good care of you.”
Forrest General also added a greeter outside the ED entrance who helps people in and out of vehicles and can summon additional assistance. The ED’s goal is to keep LOS under 200 minutes for all patients, and it reaches that goal about six out of seven days, Nelson says.
Shappley notes that the team stays on top of the metrics and looks for any opportunities to tweak the system for improvement.
“Our management team is looking every day at the matrix and wondering why it took so long to get this scan done or whether there is any trend,” she says.
“When we find something, we don’t look at it as a problem, but rather an opportunity to improve on what we’ve already done.”
- John Nelson, MD, FACEP, Medical Director, Forrest General Hospital, Hattiesburg, MS. Phone: (601) 288-2190. Email: firstname.lastname@example.org.
- Sheila Shappley, RN, BSN, MBA, Emergency Department Nursing Director, Forrest General Hospital, Hattiesburg, MS. Phone: (601) 288-2177. Email: email@example.com.