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There is no denying the appeal of immediate bedding. When it works well, patients get attention right away, and their needs are addressed in short order. But veterans of the approach will tell you that making such a practice a reality in a busy ED requires administrative commitment and persistence.
Teresa Kreider, MSN, RN, led the charge to implement the approach when she was the ED director at Reston Hospital Center in Reston, VA, back in 2007. Results were impressive: Door-to-physician times, the leave-without-being-seen rate (LWBS), and overall length-of-stay in the ED all declined dramatically while patient satisfaction increased. And the Reston ED became a model for other nearby hospitals interested in pursuing the approach.
Now, as director of the ED at Henrico Doctor’s Hospital in Richmond, VA, Kreider is hoping to push the envelope even further with additional refinements, including a new enhancement that enables patients to electronically check in to the ED, using a kiosk stationed at the front of the department.
"My long-time philosophy is that no patient belongs in the waiting room," says Kreider, noting that she is always searching for new and better ways to connect patients with providers more expeditiously. However, Kreider acknowledges that this is a priority that is continuously challenged by nurses and physicians who are much more comfortable with the traditional linear way of providing emergency care.
Take the practice of "swarming," for instance. This is where the physician, the nurse, and a tech all surround the patient at the same time as soon as he or she is brought back to a room for care. With this approach, the patient does not have to provide information more than one time, and treatment decisions can be made quickly. "Although people can see the benefit in swarming, in the other part of a nurse’s brain, she wants to do her own thing," says Kreider. "She wants to go in and meet her patient, she wants to bond, she wants to connect with him or her for a few minutes. And she wants to do all that in her own rhythm."
Physicians often have similar reservations, preferring to see their patients one on one after a nurse or a tech has completed preliminary tasks. It is what they’re used to, so it can take time to win them over to doing things differently, says Kreider.
While swarming typically takes repeated practice before it jells, doctors and nurses who develop the skills to work in tandem in this way make good medical teams, notes Kreider. "We’ve talked about identifying specific teams so that a doctor is always on the same team," she says. The ED is divided into three zones, so assigning specific teams to each zone could potentially work in the department, and Kreider believes that putting personalities that mesh well together could enhance the effectiveness of the approach.
Kreider also looks for opportunities to educate or inform staff about how swarming can most effectively work. For example, when a member of her emergency nursing staff, Robyn Bolick-Maass, RN, BSN, did extensive research on swarming as part of a graduate degree program she was involved in, Kreider invited Bolick-Maass to share what she had learned with the rest of the staff.
Bolick-Maass looked at the use of swarming in many industries, not just healthcare, but in the ED she sees it as the most efficient way to care for a patient. "It’s about optimizing the performance of each person and improving the speed of care at the same time," she says. "But with any new idea or change in practice, it is hard for nurses in general."
Consequently, Bolick-Maass stresses that it is important for staff to have a solid understanding of what the practice is and how administrators envision it being implemented before the new practice is launched. "Explain to them that it is going to be a hard transition, but that it is going to lead to better outcomes for patients," she advises.
It should make nursing jobs easier over the long run because nurses will be working as part of a team, according to Bolick-Maass. "They will not be in the room by themselves with a patient trying to get everything done," she says. "If they understand why you are doing it rather than just being told to do it, staff will more easily grasp the idea."
While swarming offers many benefits, administrators need to understand the potential pitfalls as well. For instance, Bolick-Maass points out that the approach is very hard to implement if a department is understaffed. "You really need that nurse and a doctor and a technician in the room when a patient hits the bed," she says. "So look at how it will work if one of those team members is not there and you can’t get someone to replace that team member."
Similarly, it is important to have contingency plans for days when volume is high and all of the beds in the ED are full. When this happens at Henrico Doctor’s Hospital, Kreider puts a nurse out front to triage patients. "Then they become the triage nurse’s patients," she says.
The hospital is not a trauma facility, but the ED stays busy, seeing about 2,500 patients a month, 23% of which are hospitalized, says Kreider.
Another strategy that can help with unanticipated bottlenecks is the creation of a nurse expeditor, a new position that Henrico Doctor’s Hospital just implemented in January 2014. "This is a nurse who floats," explains Bolick-Maass. "If three people walk into triage at the same time, the expeditor can come out to triage and grab one of those patients, take him back to a room and begin his triage instead of having the patient wait in line."
Similarly, the expeditor will step in if a patient is ready for discharge and the primary nurse is tied up elsewhere. "The expeditor can take patients upstairs when they are admitted or run to the lab or the pharmacy if we need something," says Bolick-Maass. "The expeditor is basically a runner, but since this person is a nurse, he or she can also educate the patient, medicate the patient, or counsel the patient."
Further, any time a clinician needs to perform a procedure on a patient such as a lumbar puncture, a central line, or a lung decompression, the expeditor can step in to assist. "You’re talking about a process that can last as long as an hour," says Bolick-Maass. "That is a long time to have a nurse tied up when she may have three or four patients to take care of. That is when the expeditor can help."
For the position to work well, the expeditor needs to be an experienced nurse who works quickly and efficiently, not someone who is new to the profession, says Bolick-Maass. "You don’t want someone who works at their own speed. You want someone who is really on the ball, and can move [where they are needed] without direction," she explains.
Typically, the expeditor and the charge nurse work together to keep patients moving, but that doesn’t mean that the expeditor relies on the charge nurse to tell her or him when to step in, says Bolick-Maass. "You want the person to be very self-directed," she says. "This truly is an extra set of hands that is very versatile throughout the ED."
One challenge that administrators are likely to run into when implementing a swarming-based approach is staff negativity, says Bolick-Maass. "We are optimizing care, so this is going to make everyone work with their A’ game all day long," she says. "You are working with a team, but you are working at a very high pace, and not all staff members want to work at that pace."
For instance, Bolick-Maass has documented that swarming can trim as much as 10 minutes off the time it takes to do all the tasks associated with assessing a patient who presents with chest pain. "If a nurse is in the room by herself, you are looking at 15-20 minutes, and that is assuming everything runs pretty smoothly, the patient has great veins, and he is able to sit still for his EKG," she explains. "[Alternatively,] if you have a team including a nurse, a technician, and a doctor in the room at the same time you can do the whole process in five minutes."
Swarming is a little bit like running a code on every patient, according to Kreider. And she thinks the idea of treating everyone in the same quick and efficient manner makes a lot of sense. "That sort of mentality is good," she says.
However, operating at a higher pace requires staff buy-in as well as a process that has been carefully designed to suit the facility’s capacity and community needs. "While we all do the same thing, EDs are very different because of location, types of patients, volume, and rooms available," says Bolick-Maass. "So it is hard to just initially throw this out there without really delving into the structure and staffing of the group."
Kreider advises administrators to model the kind of behavior you want to see and identify champions. For instance, she has one nurse who exemplifies the kind of behavior required for swarming. "He tries to direct everything through a team approach when he is here, and he is part of that team so he models the behavior," she says. As a result, staff members see the approach working smoothly when this nurse is involved. "He understands that if we all think in the same way, then the team approach is a win/win for emergency medicine."
Even with ample improvement, Bolick-Maass observes that the practice of swarming is still a work in progress in the ED. "We are not to the point where this is standard procedure. This is still very new for us," she says. "Some days we can do this very efficiently if we have the right nurses and doctors, but we are definitely not to the point where we are 100% yet."
However, average arrival-to-bed times typically hover at around six minutes, and patients are generally connected with a provider within 20 minutes. While these are impressive metrics, Kreider observes that the bar is always being raised. Consequently, while she pushes the staff for greater mastery of swarming, she is hoping that the new electronic check-in process will further tighten wait times and nudge patient satisfaction upwards.
Patients use the kiosk to submit their name, date of birth, and chief complaint, and then a nurse can quickly transfer that information over to the ED’s documentation system with the click of a computer key. "There is some speed to it," says Kreider.
However, Kreider still maintains licensed personnel out front because she wants a clinician to know right away if a patient presents with chest pain or another problem that needs to be addressed right away. "I believe in nurses seeing patients first, registration second," she says.
Another move that is making a sizable dent in overall LOS is point-of-care testing. Some test results that used to require more than an hour to come back from the hospital’s central lab are now available within minutes because the tests are now conducted by on-site personnel. "We hardly need [the central] lab for anything except urinalysis now," says Kreider. "How long a patient is in the ED, how long it takes to be admitted, and how long a patient waits for a bed are all things that are being measured now. We have to come up with strategies and processes to have a winning department."