Patient Flow Solutions

Improved flow aids patient safety

Cut wait times, LWBS, boost compliance

If there are any doubts that improving patient flow also enhances patient safety, the recent experience of the ED at Enumclaw (WA) Regional Hospital should dispel them. A new triage and treatment process has dramatically improved flow performance, but it has also garnered the ED the Washington State Medical Association's 2010 William O. Robertson Patient Safety Award.

Richard Dickson, RN, the ED manager, explains why. "Our rate of patients who left without being seen had been 5%, and we dropped it to between .8% and 1.1%," Dickson says. "When we examined the records of the patients who had left before being seen, we discovered that on average they were level three patients." The ED uses a five-level triage classification, with level 1 being the most serious.

A level 3 patient "is someone that needs to be seen," Dickson says. An example is a patient with abdominal pain. "I like to think they went to another hospital, but they also could have gone home and bled out," Dickson notes.

In addition, he says, the department's AMAs (Against Medical Advice) also have dropped, from 1.5% a month to less than .5%. "Patients used to think that what the doctor ordered was either too costly or too time-consuming," Dickson notes. "Since they're being seen much earlier, they tend not to run out before the doctor finishes treating them."

They certainly are being seen more quickly. The door-to-doc time has dropped from an average of 52 minutes to an average of 16 minutes, Dickson reports.

The new process was "borrowed" from a sister hospital, St. Anthony Hospital in Gig Harbor, WA, which implemented its process in March 2009. Enumclaw went live with theirs in early 2010. "It was a brand-new hospital, and we wanted to develop a process that was very patient-centered and designed to meet their needs and expectations," explains Paul Hildebrand, MD, regional medical director for emergency services in the Franciscan Health System, which is based in Gig Harbor, WA.

In seeking models, Hildebrand discovered that his group's parent organization, TeamHealth, had developed an effective process for Banner Good Samaritan Medical Center in Phoenix and for Memorial Hermann Hospital in Houston. "We went to Phoenix and observed," he says.

When patients present, says Hildebrand, they are greeted and "brought right back," where they are seen by a physician/nurse team. "They do not spend a lot of time out front or go through the redundant exams you see in a lot of places," he says. Once a treatment plan is created, it is discussed with the patient.

At St. Anthony, says Hildebrand, door-to-doc time is about 10 minutes and LWBS is "essentially zero." If a patient needs to be admitted, a nurse from the inpatient area comes down and takes the patient upstairs. "So our staff is able to continue seeing new patients," Hildebrand says.

One difference between St. Anthony and Enumclaw, notes Dickson, is that his staff is too small to allow a dedicated triage nurse. "We have two RNs 12 hours a day and three the other 12 hours," says Dickson, adding that they basically take turns as the triage nurse.

When patients present at Enumclaw, one of two registration clerks take down the chief complaint and "quick-reg" the patient to give them an account number. "They then call the team intake [triage], and they come and take them either straight back to a patient room or to a triage room, depending on their triage level," says Dickson.

Level 4 or level 5 patients, who are seen in the triage area, then wait outside the X-ray and lab areas (which are not in the ED), sitting on waiting benches provided for them until their results are back.

'Train ticket' tracks patients

In the ED at Enumclaw (WA) Regional Hospital, lower acuity patients are provided with a form that is called a "train ticket," which helps staff keep track of the progress of their care.

"As soon as they are done with 'team intake,' or triage, the nurse will check a box indicating triage is complete and ask them to take the form with them, because when they sit on their bench outside of X-ray, where they wait for results, the techs will come and look for people with these pieces of paper in their hands and initial them when the labs or X-rays are completed," notes Richard Dickson, RN, the ED manager. [A copy of the form is available.]

Dickson says the form grew out of a series of weekly interdepartmental meeting that were held as a new patient flow process was being launched. "The key to getting staff onboard is involving the registration department, the lab, and imaging to get buy-in," he says. During the weekly meetings, comments were solicited about the process. "We thought we knew everything, but they threw out the ticket idea and said 'What about this?'" Dickson says. "It's been invaluable."