'Line at the door' is tackled first
When the ED leadership team at Peninsula Regional Medical Center in Salisbury, MD, set out to improve throughput, the first thing they tackled was the line at the door, says Clark Willis, MD, medical director.
"Patients were lined up at one window trying to get registered and triaged," Willis recalls. "The attitude was that we didn't 'own' the patient until they got past that wall."
Process changes to address this issue included putting a greeter in the waiting room to be sure patients with more urgent needs were seen first and streamlining the triage process so patients would get to treatment more quickly.
Susan Castrignano, RN, BSN, the nursing director, says, "The ED had been expanded from 19,000 square feet to 41,000 square feet, but as much input as we had into the design, when our volume went up, we still had issues. Instead of a full triage, if there was an open bed, we started bringing the patients straight back. You could bring four or five people back at the same time, and it all happened in parallel."
To help make this possible, changes were made to the electronic medical record screen to prevent nurses from performing a full triage and directing them to just do a "mini-screen," Castrignano says.
"The content of the triage was not changed, but the team felt it was important to separate the screens and have the triage nurses do the first initial screen and the primary nurse who would be taking care of the patient the second part, which contains the past medical history and medication reconciliation," she says.
The traditional culture of the staff was to do as much as possible in triage and not to dump the work on the primary nurses, Castrignano says. "But when the question came up as to what was best for the patient, and the goal is to have the patient see the provider, the majority of the nurses were supportive about the process change," she explains.
As with all of the changes made in this ED, teamwork was a critical element. Willis says. "We involved the nurses in the decision-making. We had a focus group process improvement, rather than just pronouncing the change."
The nurses received one-on-one training from other nurses. They walked through the new screening process and seeing how to get patients back to the bed more quickly. "The doctors were recipients of education, too, since they had to hop in and see those patients with the understanding that they may not have been completely triaged," Willis says.
The new attitude of cooperation manifested itself when a problem arose with the express care unit. "When we started to bring patients straight back, we had to protect express care, because staff tended to grab mid-level people to protect the doctors," Willis says. "They were poaching from express care to fill their own needs. We agreed to protect express care staff; that doctors would not pull mid-level staff, and nurses would not pull nurses or techs."
The result? Despite the fact that express care saw a 21% increase in volume, its throughput went from an hour and a half to under 60 minutes.