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Patient satisfaction surveys conducted by EDs typically list the same No. 1 complaint: It takes too long to see a physician. Some forward-thinking ED managers are addressing the issue by registering patients at their bedside instead of in a waiting room. Those who have switched to bedside registration report a dramatic rise in patient satisfaction.
"The patient really feels you’re making good use of their time," says Lindy Rose, RN, director of the ED at Harris Methodist-Fort Worth (TX), which became one of the first EDs in the country to switch to bedside registration when it started the program three years ago. "They appreciate not getting moved all over the ED for your convenience."
Bedside registration often is part of a broader re-engineering process. When St. Ann’s Hospital in Westerville, OH, was re-engineering the ED, registration became a key issue. "We always had an initial cursory triage first; then the patient would sit through the registration process and provide all the demographic information and then go through a more thorough triage," says Bobbi Allen, RN, center leader of the emergency care center. "We decided we should be doing triage in the true sense right up front, and get the patient to the spot where they will be seen."
The positive results are tangible on the ED’s satisfaction surveys. In the "random comments" section, patients say things such as, "I really like that you asked me all the medical questions first, and then I went to a room for registration," says Allen. "I’ve been getting specific comments like that. Patients appreciate that they were paid attention to medically first."
Putting the patient directly in a room and having the registration person go to the patient is much more customer-friendly, says Joseph Simon, MD, medical director for integrated care delivery and former medical director of the ED at Scottish Rite Children’s Medical Center in Atlanta, which recently switched to bedside registration.
During a 1994 re-engineering effort at Harris Methodist, focus groups revealed that the ED’s registration process was a major sore spot with patients. "Patients had a rather glaring perception that we were only interested in their insurance because we got registration information before they were in the treatment room," Rose recalls. "They completely forgot that a triage nurse had welcomed them in, done an assessment on them, and gotten all the clinical information so we were sure the sick people were going straight back.
"The bottom line was that patients wanted to see a doctor, be treated, and leave. We realized we were making ill and injured people wait in line to be checked in, go to the registration clerk’s desk, and then be placed out in the lobby if they weren’t urgent. There was a real opportunity to improve their perception of us by changing the way we registered patients."
The challenge was to immediately place patients in a treatment room where the care providers and clerks could come to the patient. "Clearly, patients wanted to go straight back to a room, so we figured out a way for that to happen," says Rose.
The patients’ positive reactions to the change surpassed all expectations. "They’re shocked when we ask them to follow us to a room," says Rose. "They’re fumbling with insurance cards, saying, Don’t you want to see this?’ We tell them, No, the registration clerk will come to you later.’"
The time it takes for a patient to get inside a treatment room has been dramatically reduced. "Within five minutes of arriving, they’re sitting in a treatment room so the doctors and nurses can get to them right away, whereas with our old process, our minor patients had to wait [an average of] 52 minutes to go through triage, registration, and then wait in the lobby," she says.
Bedside registration also has streamlined patient care. Before, even if a doctor wasn’t doing anything, he still couldn’t see the patient until registration was completed. Now doctors can see patients within five minutes, even if the nurses and registration people are busy, says Rose.
Making the switch to bedside registration doesn’t necessarily mean a huge financial investment. Many EDs use laptops that are hooked into the main hospital network. If that isn’t possible, bedside registration is still an option, says Rose.
When Harris Methodist’s ED implemented bedside registration, no computers were added. "In the beginning, we tried to do it with laptops, but we couldn’t establish connectivity with the technology we had at the time," she explains. Instead of using laptops, registration information is taken manually and immediately re-entered into the system.
More than half of the ED’s patients are already in the hospital’s computer system, which saves time. When patients walk into the ED, they give the triage nurse their name, date of birth, and Social Security number. "The triage nurse gives the registration clerk a copy of the patient’s chart using that information, so the clerk can pull up a file if we already have one," Rose says. "When the clerk enters the treatment room to register the patient, the information is confirmed."
A data sheet based on the information requested on the computer screen was designed for patients who aren’t yet on the hospital system. Once the patient is in a room, the clerk comes in to record the registration information manually on the data sheet and then immediately leaves to enter it on the system. A clipboard contains the data sheet and patient consent forms.
The manual system worked for several years, but the ED recently decided to convert to laptops in order to save time. "We decided to switch to laptops because of the double work involved with entering information for patients not already in the system," says Rose. "We expect it to save us at least five minutes per patient from having to do it by hand. Three laptops will be purchased initially [and] stored on carts along with registration supplies."
When Scottish Rite switched to bedside registration, the ED added 26 computer monitors and keyboards. The financial outlay isn’t that great, Simon notes. But, the department must consider whether saving patients a stop at the registration desk is worth having them in bed longer and worth the possible friction between clinical and clerical staff attempting to work together in small rooms, says Simon.
You may end up with a patient who has had a history and physical done but has not been registered or signed consent, he says.
"Cost savings aren’t much of a factor. I don’t think it saves any time or money because you’re still collecting the same information in the same way; you just have one less stop," says Simon. "Increasing patient satisfaction is the prime motivator for switching to bedside registration."
Bedside registration brings with it other operational changes that may ruffle some feathers. Problems may arise when clerical staff accustomed to working behind desks are suddenly expected to be out on the front lines of patient care.
Bedside registration has only been in place at Scottish Rite’s ED for about two months. Several of the ED’s clerks are unhappy with the situation. "We’ve met with a fair amount of resistance there," says Simon. "They aren’t thrilled with it and sometimes actually try to capture patients up front. For example, if two parents come in, they’ll have one parent in triage and the other parent register."
Yet some clerks welcome the change. "The ability to walk around and get in the action a little bit might have some appeal to someone who doesn’t want to sit at a desk all day," Simon suggests. Most of the registration clerks at Harris Methodist’s ED welcomed the chance to work alongside the clinical staff. "They’re a major part of our team and didn’t like being sequestered in an office setting away from us," Rose says. That wasn’t true of everyone, however. "There are some folks who don’t want to go into the clinical areas and were very happy to have a big desk dividing them from the patients," she notes. "They’re concerned about bodily fluids and that sort of thing, but I feel that’s just an education issue, and once they understand how to safely protect themselves, it won’t be an issue.
"As with any major operational change, you run the risk of losing employees who can’t cope. Some folks felt it really changed their job dramatically and didn’t like it, so you lose a few that way, but some of the others just love it and really feel a part of the team," says Rose. Task meetings were held to work through the issues.
The size of treatment rooms is also becoming an issue due to the growing population. The addition of a registration person makes the room even more crowded. "We make do, but our rooms are a little small to begin with," says Simon. "Now, you’ve got another couple of square feet taken up, and it can be a problem."
Staff may be challenged to take turns in the room or navigate around other staff. "We have very small rooms, and the registration clerk is just one of several people trying to get in the technician may come in with an [ECG] machine, and the X-ray person might come in with portable X-rays," says Rose. "Some were intimidated by it at first, but they have learned how to compete for their piece of the patient’s time."
Another potential problem involves uncomfortable interactions among staff in a crowded room that was once reserved for clinical staff. Inevitably, the registrar ends up taking second place to the clinical players, which makes for hard feelings. "Clerical staff often find it awkward because they find themselves pushed around by doctors and nurses," says Simon. "We’re trying to develop an electronic system to identify exactly when the registrar should go into the room, when the patient is most available to them."
At Harris Methodist, the ED’s admission clerks were moved from the front registration desk back to the patient areas. The proximity of the clerks to the patient rooms improves the lines of communication. "Now, when a patient is put in a room, the triage nurse gives a copy of the nursing chart to the registration clerk, who knows she has this patient in that room and goes to check them in,"says Rose.
Ultimately, bedside registration brings clerks into the team. "The registration folks reported to the business office before this, and now they report to me," says Allen. "I like that aspect of it, and I think they do, too. They feel a part of the unit in which they work, and that feels good. "
Along with bedside registration comes some decision making about staff roles. St. Ann’s ED cross-trained its secretaries, called unit coordinators, with the registrars, combining both functions in a single job. The new job title is administrative partner. "There is a lot required of the position, and the job title conveys that," says Allen. "That person is trained to do both jobs, so they are vital to us."
Each 12-hour shift is broken up into four-hour blocks of time for order entry, registration, and a floating position. "We do that so the person doesn’t get burnout doing registration for 12 hours straight would become boring," notes Allen. "Hopefully, everybody will have experienced each part of the job several times in each shift."
Initially, the new role was difficult for staffers to accept. The registrars and the unit coordinators each saw themselves clearly in one role or another, says Allen. "Getting that mindset to change, to see it’s one job now, was the hardest part. Two or three people were real proactive and got it right away, but it took others several months. Now, two years later, some still see it somewhat separately. But with any new people I hire, that’s all they know," she says.
Training was done internally by registration clerks and unit coordinators who excelled at their jobs. "We had a couple of real whiz bangs in both roles; we taught them up front, and they taught the others," Allen explains.
Bedside registration also allows for better staff utilization. "Now, if there is a backlog in registration but the doctor is available, they can still go in and see the patient, says Simon. "It creates a bit of a problem if he needs to order something for the patient, and they’re not yet registered, so his orders might have to wait a few minutes. But from the patient’s perspective, things are happening, and it’s a better use of the doctor’s time because he doesn’t sit around doing nothing while the patient is waiting at registration."
To reap the full benefits of bedside registration, the process may need to be tweaked after implementation. At Harris Methodist, physicians at first were unable to see patients because they were waiting for the bedside registration to be completed. The solution was creating a physician chart that wasn’t computer-generated.
"Waiting for the registration clerk to get all the information and print a chart was what hung us up," Rose explains. "The physicians really didn’t need that chart to treat the patient." Another downside of the computer-generated chart is that demographics took up a third of the chart or more, which didn’t leave the doctors much room to write anyway. As a result of the new chart system, the physicians aren’t held up by the registration process, and waiting times have decreased."
Some EDs find that bedside registration is most effective when used selectively for certain types of patients. Scottish Rite’s ED does bedside registration only for urgent patients. "By our definition, that comprises over half of all our patients, but you have to provide for that contingency when a patient is not going to be put in a room right away and would be sitting in a waiting room anyway," says Simon. "We choose to register those patients outside because it’s more efficient, but if a patient is going into a room promptly, we try to register in the room."
Registration isn’t the final frontier of services provided to patients in a single treatment room. At Harris Methodist, patients can be registered, treated, and even pay their bills without leaving the room. "After the visit is over, instead of sending them to a dismissal area where they stand a chance of waiting in line for the privilege to pay, we come into the patient’s room, where there is privacy, and discuss their options," says Rose. The process takes place when the patient is already waiting for aftercare instructions or prescriptions, to minimize the time spent waiting.