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ED makes lemonade out of lemons
Inadequate intake system vastly improved
An adverse event in the ED at University Medical Center (UMC) in Las Vegas might have drawn negative media coverage and state and federal investigations, but it also led to process changes that the ED managers say have made a world of difference in patient satisfaction and quality.
"The problem was an incident that began at one of our outlying clinics, which we call Quick Cares," says Dale Carrison, DO, MS, FACEP, FACEOP, chairman of emergency services at UMC. He adds that ongoing legal action prevents him from going into too much detail. "They called the ED and advised us that a patient a female with abdominal pain was coming in her own vehicle. She had chosen not to come by ambulance."
There are varying versions on what happened once she arrived in the ED, says Carrison, "but she waited for a significant period of time for too long," he notes.
An aggravating factor was that the woman was pregnant. However, the outlying clinic had not detected the pregnancy, and in fact, according to Carrison, the woman herself did not know she was pregnant. There was a delay in seeing the triage nurse, and the patient left on her own. According to local press reports, she tried another hospital but was told the wait there would be a long one, was given pain medication, and went home, where she delivered a premature baby girl. Paramedics failed to revive the baby, say the reports. The patient and her fiancé subsequently filed a complaint alleging that she was ignored in the ED so long that she and her fiancé returned home.
Following the investigations, including one by the Centers for Medicare & Medicaid Services, and the request for corrective actions, Carrison put together a team and conducted a root-cause analysis on all that had happened. "We looked at every portion of the system to determine the best odds of preventing this from happening again," he says.
One of the changes already had been under way, but the team decided to further modify it. "In the real old days, a patient took a number and sat down. We realized that was not good, and [we] went on to have a CNA get an initial chief complaint, put the patient's name in the computer, take vitals, and then forward the information to a triage nurse," says Carrison.
More recently, however, the department had implemented a rapid medical assessment (RMA) process, with a doctor in triage from 9 a.m. to 6 p.m. When this event occurred after 6 p.m., the team decided to extend the RMA hours until 3 a.m.
During those hours, the patients are now seen by a nurse "meeter/greeter," says Evelyn Lundell, RN, MSN, the clinical manager of the ED. In addition to performing the "mini-medical" initial assessment, "they can offer an extra eye that is trained to pick up a patient that might be deteriorating and cause an unfortunate death, such has been seen EDs across the country," she notes. The nurse enters the patient information into the computer and obtains a pain level and chief complaint. A rapid registration is performed. The patient is seen by the RMA doctor, who orders treatments and tests.
"He may be able to discharge the patient or expedite them to the back, during which time the nurses initiate the testing, get labs drawn, and finish the triage from the nurse's perspective," says Lundell.
Carrison says he is collecting data to evaluate those changes, which have been in place only a few months. However, he says, "Anecdotally, I can tell you that adding RMA hours has absolutely made a difference in this 53-bed ED." UMC, he adds, has completed its corrective actions.
ED and outside clinics expand communications
To prevent a repeat of an adverse event that resulted in state and federal investigations, the ED at University Medical Center (UMC) in Las Vegas has improved communications with the facility's outlying Quick Care clinics, as recommend by a team that conducted a root-cause analysis of the event.
"We've changed how transfers come from Quick Care," says Dale Carrison, DO, MS, FACEP, FACEOP, chairman of emergency services at UMC. The hospital has an area named the Patient Placement Center that handles outside transfers. "Quick Care now calls that center, and the patient is already in our system," he says.
This change saves time by avoiding dual registration, he says. In addition, "if this patient has already been seen by a physician, they should not go to the back of the list when they get here, but to the front," Carrison says.
Evelyn Lundell, RN, MSN, the clinical manager of the ED, says, "They've already waited two or three hours at Quick Care." However, the more serious patients obviously receive priority in the ED, she says.
Carrison says, "If you take dual registration out of the process, that saves probably 10 minutes per patient a minimum of five. And there's less chance of a patient falling through the cracks when they come via ambulance."
In the adverse incident, the patient insisted on driving herself to the hospital, he says. "Now we ask the patient to sign a form saying they've refused transport by ambulance," says Carrison.
If patient feels pain, it's real
It's important for ED nurses to acknowledge that a patient's pain is real to them, even if they have their own doubts about its legitimacy, says Evelyn Lundell, RN, MSN, the clinical manager of the ED at University Medical Center (UMC) in Las Vegas.
"It is not our job to determine if the pain is real or not. It is real to them, and we need to acknowledge that," she says. "If they say it's a nine, then we need to assume that it's true, even if they're smiling and do not seem to be in pain."
A nurse can document that the pain assessment is not consistent with the patient's behavior if they wish, Lundell adds. Pain issues have even led to process changes in the ED, she says. "We give PO meds in the waiting room now because of pain complaints," she says