Make these changes to cut delays, diversion hours

Triage protocols and teams yield dramatic results

A sharp decrease in hours on diversion. Decreased length of stay. Greater staff satisfaction.

These three items are on every ED manager’s wish list, but they are real-life examples of changes made as a result of one ED’s participation in the GE Medical Systems Six Sigma process, reports Patricia Bunce, RN, BSN, CEN, director of emergency and critical care services at Good Samaritan Hospital in Dayton, OH.

General Electric (GE) has used a quality improvement process known as "Six Sigma" in manufacturing for years, which consists of a five-phase, problem-solving process called "DMAIC" — define, measure, analyze, improve, and control — that ensures lasting change, says Bunce.

GE has now created a division that helps health care organizations improve, based on the Six Sigma process, she explains. The process eliminates unproductive steps and uses technology for improvement, and it has had a dramatic impact on the ED’s operations, she reports.

The GE consultant team was hired for one year. A "Master Black Belt" from GE, a specially trained individual acting as a team leader responsible for teaching the process to staff, was given the position of vice president of strategic improvement at the facility, Bunce says.

An ED supervisor and Bunce were trained as "change facilitators," which includes holding regular problem-solving meetings with ED staff, with subgroups designated to implement solutions. "It has been extremely successful," she says. The ED’s original length of stay averaged 326 minutes from placement in a treatment room to discharge, which decreased to 180 minutes after key changes were made, Bunce explains. There also has been a dramatic decrease in diversion hours since a "zero reroute commitment" was made in January 2003, Bunce reports. In February 2002, the ED was on reroute status 107 hours, but a year later, diversion hours totaled only six — a decrease of 94%, she adds.

Here are two key changes that were made:

Triage protocols were implemented for early blood draws, urine specimens, and intravenous (IV) lines.

The ED had a problem with delays in collection of lab specimens, says Bunce. As a result, blood, urine, and IVs now are started routinely at triage for certain chief complaints, she says. "Instead of a lab tech making his or her way around the ED, we trained our nurses and paramedics to draw blood at the time of the IV start and send it to the lab," she explains. The laboratory holds the specimen until the actual order is received, she says. "This reduces time from order to collection to zero," Bunce says.

Nurses and paramedics work together

Urine specimens are collected at triage or as early in the visit as possible for patients who are brought by ambulance, she says. "We are also working on protocols including standing orders for urinalysis, urine pregnancy, and some blood tests," she adds.

Nurses and paramedics work as a team.

The ED now uses a "team concept" consisting of a nurse and technician or paramedic, says Mary Porter, RN, nurse manager of the ED. "The technician and paramedic roles have changed so that they feel more like a part of the patient care team," Porter says.

Before, technicians and paramedics were frustrated because they didn’t know what care the patient needed until told by a nurse, Bunce says. "Now, all members of the team receive report on the patient," she explains.

Previously, the technicians and paramedics assisted all of the nurses simultaneously and often became overwhelmed with all the requests for help, Porter says. "Nursing staff had to hunt for someone and frequently could not find a tech or paramedic who was available," she explains. Now, the technicians and paramedics do not float to other teams unless requested by the charge nurse, she explains. "When they do leave the team for other tasks, they communicate this to their team members," Porter says. Previously, if repeat vital signs needed to be taken, the nurse would have to locate a technician or paramedic to do this, and if one could not be located, the nurse would perform the task, says Porter. "This led to delays in accomplishing the task," she says.

The task now is delegated routinely to technicians and paramedics, who are given specific times for repeat of vital signs based on preset acuity parameters, says Porter. "This helped to create the personal accountability to accomplish the task and subsequently improved the standard of care," she says. Technicians also are assigned to specific areas, such as triage or electrocardiograms, says Porter.

They also are assigned to specific patients, Bunce adds. Previously, the technician who brought a patient back to a bed might not be the same technician who cared for the patient during his or her stay in the ED, she explains. "Now, when a bed is empty, the tech on that team brings the patient back, gets him or her ready to be seen, and that is the same technician who will meet any personal needs and work with the nurse caring for the patient," Bunce says.


For more information on the GE Medical Systems Six Sigma for Healthcare process, contact:

Patricia Bunce, RN, BSN, CEN, Director of Emergency and Critical Care Services, Good Samaritan Hospital, 2222 Philadelphia Drive, Dayton, OH 45406. Tele-phone: (937) 278-6251, ext. 1332. E-mail:

Mary Porter, RN, Nurse Manager, Emergency Department, Good Samaritan Hospital, 2222 Philadelphia Drive, Dayton, OH 45406. Telephone: (937) 278-6251, ext. 1333. E-mail:

• For more information GE’s Six Sigma for Healthcare, contact GE Medical Systems, N16 W22419 Watertown Road, EC-05, Waukesha, WI 53186 Telephone: (877) 438-4788. Fax: (262) 544-3384. E-mail: Web: