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'No wait' policy has broad goal
Improved community care is sought
There's no doubt that when the Bon Secours system in the Hampton Roads area of Virginia launched a new "no wait" policy for its EDs, it was hoping to improve its brand and attract more patients. However, its goal was broader. After all, it already was successfully fulfilling its guarantee of seeing all patients within 30 minutes. As part of that guarantee, the ED sent any patient who did not see the provider within 30 minutes an apology letter and two movie tickets. That policy continues under 'no-wait.'
"What we really wanted do was to push the communities in which we were located in emergency care as a whole while building loyalty," says Jeff Doucette, RN, MS, CEN, vice president of emergency services for Bon Secours Hampton Roads. The strategy of pressuring other EDs in the area seems to have worked, he says. "In Richmond, where we have had the program in place the longest [six months], other facilities now post their wait times on the Internet," he says.
Doucette says that the new system was created in-house, with the assistance of its emergency physicians group. "We brought the plan to the table with the belief that we could provide a no-wait experience, and we certainly have done that," he says.
Basically, says Doucette, the system involves placing an RN right inside the ED entrance. "The nurse is standing up and greets the patients as they come through the door," he says. "She asks the patient their chief complaint, and the only question she has to ask herself is whether they should go to the main ED or to our Quick ER." Once that is determined, the patient is taken directly to the appropriate care area.
Prior to these changes, patients who came into the ED would be met by a greeter, says Carl F. Wentzel, MD, the ED medical director at Bon Secours Harborview Medical Center in Suffolk. Bon Secours has three hospital EDs and one freestanding ED. "They would write down initial complaints, take some basic information, and then if a triage room was available, they would go there, where the triage nurse would do a more extensive assessment," says Wentzel, who notes that his ED sees about 30,000 patients a year.
Because the RNs who now greet the patients are the more seasoned ED nurses, "they can tell quickly if the patient needs to go to a critical care room or if they need minor care," he says. A computerized system shows here where beds are available, he adds.
What happens if several patients come in at once? Can the "no-wait" guarantee still be fulfilled? It can, insists Doucette. "We have a process that includes float positions, and those people can immediately come up front," he explains. "In the past we would have been backed up, but now the nurse up front just gets on the phone." The float RNs work throughout the ED assisting primarily with throughput when they are not needed in the front, he says. When they are called up front, they perform the same duties as the "greeting" RN.
If there is not a room available, he adds, the care team comes up front and follows a series of protocols that "have been streamlined and are very specific," says Doucette. For example, he points out, the protocol for abdominal pain formerly had about 15 items; now it has only about five.
"What we've done is not earth-shattering on the front end," admits Doucette, and yet the new system has achieved significant improvements. For example, average throughput in the EDs used to be about 3.5 hours and now it is down to two hours, with most patients being discharged within 90 minutes. As for bed placement, "what typically took 30 minutes is now down to six or seven," he adds.
In the last six weeks, Doucette continues, total volumes in the EDs are now 110% over the plan budget. "We're now averaging about 116 patients a day in the freestanding ED and about 145 a day in the hospital EDs," he says.
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Process changes lay foundation
While the most visible change in the EDs in the Bon Secours Hampton Roads (VA) system is an RN who greets all patients when they enter the department, the system could not be meeting its new "no-wait" guarantee without having first laid the foundation with several process changes, says Jeff Doucette, RN, MS, CEN, vice president of emergency services.
"It took us six months to prepare for the new program," says Doucette. "To get to this point, we had to enhance all we do." For example, he says, every patient is now given an information folder, which includes his contact information so that they can provide feedback on the new system.
In addition, he says, all of the ED protocols have been streamlined. Protocols for the "Quick ER," for example, formerly encompassed 20 pages; they have been reduced to five. "We've proven that overall we can provide high-quality emergency care and do it quickly," Doucette says. (A copy of the "before" and "after" versions of the protocols is available.)
The patients seem to agree, given the comments he has been getting. "I get 10 to 15 calls a day complimenting our service, where I used to receive 10-15 complaints a day," he reports. "The staff is more satisfied as well."