Novel strategies decrease ED delays
Novel strategies decrease ED delays
Success stories to improve front-line performance
Numerous patient satisfaction surveys show that long waits are the emergency department’s (ED) No. 1 patient complaint. Unnecessary delays can heavily impact patient care and the bottom line. Reducing the amount of time a patient spends in the ED is a top priority for managers who want to boost satisfaction with what is often the entry point to their facilities.
"It’s always been an important issue, but with pressure from managed care organizations to maintain high service quality, it’s now something we need to pay intimate attention to," says Fran Damian, MS, RN, director of nursing and patient services in the emergency services department at Boston Children’s Medical Center.
The long wait for care in the ED is a key issue. "It’s definitely the thing that upsets parents the most," Damian says. "They get turned off by the wait, with good reason. They’re not necessarily waiting in the most comfortable quarters, and kids are tired, crying, and hungry, so every minute seems like an eternity."
Although reducing patients’ overall length of stay is always a major goal, looking at the big picture can be daunting. Dividing an ED visit into specific segments can motivate staff. "From a staff perspective, when they are trying to hustle and take advantage of every second they have, to see the time data come out the same is discouraging," she observes. "But when we break it up into aspects of the visit or look at a subset of the population, they can see huge gains and it feels rewarding."
Many departments involved
Tackling wait times in the ED is especially challenging because many changes hinge on the practices of other departments. "It’s hard because so many things contribute to waits and delays, many of which are out of our control," Damian says.
In recent months, the Institute for Healthcare Improvement in Boston has completed a series of studies on reducing ED waits and delays. Nine EDs participated in the project, each with the goal of reducing wait times for a different aspect of the ED visit.
Here is an overview of some of the results.
The ED at St. Mary’s Health Center in St. Louis reduced the time it took to get a patient from triage to a treatment room. "We started with the cycle we had the most control over, which was the door-to-room time, so we looked at the registration process first," explains Marianne Fournie, RN, BSN, clinical director of the ED at St. Mary’s.
Previously, patients were triaged, went through registration, and then waited to be brought to a treatment room. The ED switched to registering patients during the visit. A small amount of information is obtained initially, which generates a chart and an account number. "Then we register them during the visit, which shaves off between 20 and 40 minutes of wait time," Fournie says.
The ED chose to focus on this segment of the visit for two reasons. "We knew results would be immediate, and it was also the one cycle that we as a department had total control over," she says.
It took some time for employees to get used to the process changes. "We brought in laptop computers that interfaced with the main system, so the secretaries could enter the registration information at the patient’s bedside without ever leaving the room. But at first, they were reluctant to use them," she says. "Also, staff were still of the old mindset that patients had to be triaged first."
Patient satisfaction improved, which helped the department’s bottom line.
"Customer complaints have gone down, and the number of patients leaving without being seen has decreased," Fournie says. "Just having six patients a day leave without being seen is enough to impact your numbers of visits per full-time employee."
Expanding process to other areas
After the process change showed results, the ED focused on reducing delays in other areas, including X-ray and lab-result times and the length of time it took urgent care patients to get through the department. A 20-minute delay from the moment an X-ray order was placed until the patient was brought to radiology was reduced to six to eight minutes. Length of stay for urgent care patients fell from 109 minutes to 88, with a final goal of 60 minutes.
"We’ll continue to reduce delays in other areas," Fournie says. "As you improve one cycle, you move on to another one."
To reduce some of the bottlenecks in the ED, some managers are making innovative use of hospital areas left unused after hours. Boston Children’s Hospital uses a day surgery space in the evenings to increase throughput in the ED. "We did it as a pilot for five nights, and it made a huge difference," Damian says. The ED has access to the area from 5 p.m. to 1 a.m., which coincides with its peak volume.
On one extremely busy night in the ED, the average wait was about four hours. "Within an hour of opening up the day surgery area, the wait decreased to about a hour, and the system was mobilized," Damian says.
The ED’s use of the space varies, depending on the volume and severity of patients on a given night. If there are several patients in the waiting room who need to be observed for three to five hours, the day surgery area functions as an observation unit. Asthmatics or patients who need intravenous rehydration are brought upstairs and monitored, opening ED rooms for other patients.
Flexibility is key
Some nights, there aren’t enough patients requiring observation to use the day surgery area. "We don’t always have that perfect mix to be able to keep the area filled. To have a nurse up there taking care of only one or two patients didn’t impact the department enough," Damian explains.
On those occasions, the day surgery area functions as a fast track. The area is staffed by a physician and nurse who treat non-urgent patients. The ED’s non-urgent area then is opened for urgent patients. "We find it to be an efficient use of the day surgery space because it allows us to open up five more rooms down in the ED for urgent patients," she says.
Removing patients from the ED waiting room seemed to improve overall waiting times. "On a few of the nights when we opened up the day surgery area, we were seeing about 200 patients a night, which is 50 more than our normal volume, and waiting times were still a little bit better than usual," she explains.
The ED at Children’s Medical Center decreased the time asthma patients spent waiting for treatment by administering medications during triage. Asthma patients are treated in a secluded alcove behind the triage desk. The treatment area is clearly visible to the nurse but not to other patients.
The ED nurses’ role expanded to include administering medication, instructing the patient, and doing reassessment and documentation. "The nurse is assuming a greater responsibility for patient care," Damian says. "At first, this met with resistance because we were adding something onto the nurse’s role, but after [the nurses began] doing it and seeing the benefit, it’s become a way of life."
Band-Aid approach effective
Though not a perfect solution, the arrangement is effective. "In some ways it’s a Band-Aid approach for the reason a patient isn’t getting into a room quicker," she says. "It makes triage more chaotic in some ways, but it’s better than having the patient sit in a waiting room not getting breathing treatments."
Wait times were reduced dramatically. "Nurses sometimes initiated meds once the patient got into a room, but waiting two hours for an exam room meant waiting two hours for treatment," she says. Currently, most patients are treated within 10 minutes, and the median wait time has dropped from 50 to 24 minutes.
Nonurgent febrile infants who need blood drawn now have the procedure done before they enter an exam room. "That way, the results are often back by the time the physician sees them. We have a phlebotomist on evenings, which helps enormously, and when they aren’t here, the nursing staff does it."
Other procedures also are done before children enter the exam room. "If we’re really backed up, the nurses will put IVs in patients before they get into an exam room," Damian says. "During overlap time when we’re changing shifts, the nurses will see who’s out in the waiting area and maybe start two or three lines before they go home."
St. Joseph’s Mercy of Macomb Hospital in Clinton Township, MI, reduced length of stay for its simple extremity patients, which comprise 15% of the ED’s ambulatory volume. "By decreasing the length of stay for simple extremity patients, it has given us more capacity to serve all of our patients in a more efficient manner," says Jan Bolton, RN, the ED’s clinical decision support analyst.
As part of the process change, nurses began ordering X-rays for extremity patients during triage. A treatment room off of the triage area is used as a "subwaiting room" for these patients. "At this point, we only put simple extremity injuries in the subwaiting room, but there are times when there is more than one patient there, so we’re utilizing the space effectively."
A radiology suite was constructed in the ED to streamline patient care. After the order prints in radiology, an X-ray tech comes to the patient, instead of waiting for a transporter. "The X-ray results are now back before the physician examines the patient," Bolton says.
A fax machine was installed so the results could be faxed immediately to the ED. "We had something in our hands sooner that way, rather than making phone calls and waiting for someone to bring them back," she explains. This enabled the ED staff to complete the patient’s chart before the physician saw the patient, so the disposition could be made at the time of the exam.
The physician now does the initial exam with the X-ray results in hand or while the X-rays are in progress. "This decreases the overall throughput time for simple extremities because the X-ray is performed earlier in the process," she says.
The turnaround time for extremity patients was reduced from a median of 132 minutes to 80 minutes. "We decreased the number of handoffs these patients experience," Bolton says. "Patients feel like they are moving through the system sooner, so our satisfaction rate has improved."
Common goals ensure cooperative efforts
It took time for staff to become familiar with the new system. "The ED registrar also enters the orders, and at times we would be sent an admitting associate from another part of the hospital who didn’t know the process, so X-ray wasn’t notified to come and get the patient," she says. "Overall, the whole process was accepted very well because they could see the impact of getting those patients through the system sooner."
ED improvement projects often depend on the cooperation of other departments that service the ED. In such situations, it helps to have the support of administration. "You need people working in the system to help identify the problems and the management level to support those changes, but you also need administration to bring the different departments together," Bolton says.
Collaboration between departments is essential. "You need to have a common goal," she says. "Initially, it was difficult working between the two departments because we were asking radiology to change their process."
Involvement of personnel in both departments helped pave the way for the changes. "Nursing staff, physicians, and radiology were all involved in the project. Without any one of them, it would not have been effective."
Reduce delays in admitting patients
At York (PA) Hospital, a significant amount of the ED’s waiting room space was functioning as a holding area for patients awaiting admission. As in many EDs, this situation created bottlenecks. "It was very important for the ED to decrease the holding time, but we were also looking to provide a smoother continuum of care for patients," says Gale Thomason, RN, BSN, the ED’s operations manager.
The first step was establishing direct communication between the two care providers. "Instead of the roundabout way of going through the admissions clerk who had no clinical knowledge and supervisors who hadn’t even seen the patient, it made a lot more sense for the provider in the ED to talk to the provider on the floor," Thomason says.
The process change eliminated several steps. "Before, a physician ordered the admission, gave it to the secretary who entered it into the computer and called admissions, who contacted the floor supervisor, who talked with the charge person. Next, the supervisor called admissions, who called the ED secretary in the ED, who would then tell the ED nurse what room they were going in, then the nurse would call the floor to give a report," she says.
The complicated process didn’t ensure correct choices were made. "All too often, we’d say this patient isn’t appropriate for that floor based on his or her current condition, then we’d have to start the whole process over again to find a different bed," she recalls.
The ED charge nurse is called a "team leader" to reflect the expanded role that entails having an awareness of potential admissions and knowing which floors are appropriate for different cases. "She now has the hospital bed board at her desk to see how many transfers each floor is getting — so we can spread the wealth — and also a housekeeping tracking board to check on the status of beds," she says.
The floor charge nurses are now paged directly and asked to take a patient. "Nine times out of 10, they’ll say yes and give us the bed number." If the hospital is busier than usual, an administrative coordinator gets involved to avoid confusion.
The ED moved from its traditional role of "pushing" patients onto the floors. "There was a history of us pushing and pushing them to take the patient, and they were pushing back saying, No we can’t’ for 10 different reasons. There’s still some of that, but not nearly as much," Thomason says.
Communication between the ED and the floors improved with mutual respect. "We’re being a little more honest with each other now," she says. "If they tell us they just got two transfers in, we say, Fine, we’ll give you a half hour.’ On the other hand, if we tell them, We have two traumas here, and you need to get them right now,’ they’ll pull the patients up immediately."
The hospital’s inpatient nurses have come to appreciate the new system. "They feel they have more control without admission [personnel] or supervisors getting in the middle of things," Thomason says. "They like the control of knowing which patients they’re getting ahead of time."
First come, first served’ frees up beds
Another major change on the floors was a "first come, first served" policy. "Beds used to be reserved for chemo, post-op, and direct admissions. Some days, three quarters of the beds were reserved," she says. "We put in 30 to 50 admissions a day through here, and it was real tough to fit them in with all the reserved beds."
The ED takes No. 1 priority over any expected patients. "They plan for these patients but don’t actually reserve the bed because if ED patients need them, they take them," Thomason says. "The only thing that takes priority over ED admissions is a patient on the floor becoming unstable. Otherwise, our patients are here, so they have to come up with a different plan for the other patients when they do arrive."
There is still some resistance to this policy. "From the floors’ perspective, if we fill them up, they don’t get any more admissions. We also tend to have the patient evaluated and stabilized, whereas their directs are more work. So if we fill up the surgical beds before the OR gets their last cases through, the floors aren’t too upset about that because it tends to be less work."
A problem sheet is filled out whenever the ED encounters difficulty with an admission. The sheet includes a checklist to explain what occurred with such options as "nurse too busy," "nurse at lunch," and "bed not ready." "The ED nurse fills them out so we can track any problems, but we average only a few a week," she says. "When you look at the volume of admissions, it’s a small percentage."
If an admissions encounter doesn’t go well, the administrative coordinator is notified immediately. "If we get a refusal and can’t negotiate with a floor, the coordinator is responsible for getting us a bed," Thomason says. "We see 55,000 patients a year and can’t take the time to keep calling floor to floor."
The administrative coordinator is closely involved in the process between the ED and the floors. Strategically positioned down the hall from the ED, the coordinator has an ED tracking board. "It’s really helped to improve their understanding of our flow because when we’re full, they see it," she says.
Training is an ongoing process
Staff training took place on an ongoing basis. "After we set up the new policy, people misinterpreted certain things or only did certain parts of it, so we were constantly going back and reviewing. We also had separate meetings with team leaders to give them an increased knowledge base about which floors take which patients."
After the new policies took effect, the average holding time for patients in the ED decreased 26%, from 59 to 44 minutes. A less tangible benefit was the improved relationship between the ED and the floors. "It’s really increased understanding between the departments, which is an age-old problem," Thomason says.
[Editor’s Note: The Institute for Healthcare Improvement (IHI) has published a "Breakthrough Series," Guide to Reducing Delays and Waiting Times Throughout the Healthcare System. The 187-page guide has a section on the ED. For more information about the Breakthrough Series programs or publications, contact Lisa Green at IHI, 135 Francis St., Boston MA 02215. Telephone: (617) 754-4800. Fax: (617) 754-4848.]
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