Cut door-to-doctor delays by 60 minutes

It’s more important than a comfortable waiting room with VCRs and fish tanks, or even an attentive triage nurse. In fact, it’s often the single most important factor impacting patient satisfaction: door-to-doctor times.

"After all, the patient didn’t come to see the nurse or registration folks; they came to see the doctor," says Mary Kate Dilts-Skaggs, RN, MSN, director of nursing, emergency and outpatient services at Southern Ohio Medical Center in Portsmouth.

In 1997, the 22-bed ED’s patient satisfaction scores were dismally low, only in the ninth percentile, and door-to-doctor time averaged about 95 minutes. After several changes were implemented, average door-to-doctor time was cut to 36 minutes by the end of 2003, and satisfaction scores soared to the 97th percentile.

To dramatically cut door-to-doctor times, use the following effective strategies implemented at EDs:

  • Use a multidisciplinary team approach.

To achieve their dramatic results, Southern Ohio’s ED nurses worked closely with physicians and registration clerks to identify and implement changes. "Having all the right players at the table when decisions are being made is a critical element," says Dilts-Skaggs.

  • Add a triage technician.

An ED nurse suggested adding a triage technician position for high-volume periods when a triage nurse alone might not be sufficient, and the idea was implemented. The technicians take vital signs while nurses interview the patient, and the technicians can escort patients to beds so the nurses don’t have to walk away from the triage area.

"We started with eight hours, but we now have a tech out there close to 24 hours," says Dilts-Skaggs.

  • Create a space for triage, nursing, and registration to work simultaneously.

The triage area was expanded to include space for nurses and registration staff to work alongside each other. This arrangement enables the patient to walk in, be seated at triage, be assessed by a nurse, and be registered — all in one place.

"If we can’t do bedside registration because the beds in the back are all full, we no longer move the patients back and forth like a yo-yo," says Dilts-Skaggs. "Instead, the staff do the moving."

  • Immediately bring back patients when a room is available.

Bringing back patients immediately allows the ED to triage and start the assessment at the same time, says Vicki Sanchez, RN, ED manager at Pomerado Hospital in Poway, CA. "Many times, the physician is actually at the patient’s bedside while the nurses are doing their assessments." This way, the patient does not have to repeat the same information again and again, she adds.

  • Have staff carry in-house phones.

Portable phones with a four-digit extension are carried by the triage nurse, charge nurse, and ED physicians and are used to notify physicians of new patients and incoming ambulances, says Sanchez. "When physicians are in a patient room, the dictation room or anywhere in the facility, we can notify them of another patient. Frequently, the physician is able to come to the room and listen to the report from the paramedics."

  • Order tests at triage.

When all beds are full, physicians always perform a brief assessment at triage.

"No patient goes back to the waiting room without the physician having seen that patient for a quick initial assessment," says Sanchez. By doing that assessment, the patient care process begins, she adds. "Tests can be ordered, and sometimes results are back before the patient is in a room."

Patients feel they have been seen quickly, at least initially, says Sanchez. "This seems to make the wait a little less stressful for the patient and the families."

Currently, after triage and registration, the admitting clerk puts in the orders that the physician has placed. "But in the very near future, when we are on-line with computer charting, the triage nurse will be able to do a quick registration of the patient while doing the initial assessment," says Sanchez. "She will be able to enter the orders all at the same time."

  • Use a tracking board to keep others informed.

A Dry Erase board is positioned outside of the physician’s work area with each patient’s last name, time of arrival, primary physician, and a space for the ED physician to update the plan for the patient, says Sanchez. Once the physician has seen the patient, he or she initials the board, which signals that the patient has been seen and the physician has taken responsibility, she explains.

The tracking board is posted outside the physician dictation room next to the medication room and is completely out of sight for visitors, adds Sanchez.

  • Notify staff of incoming ambulances.

All incoming ambulances are announced via an interdepartmental overhead page system with the estimated time of arrival, and they are announced again upon the patient’s arrival with the assigned room number. "This notifies the primary nurse, the charge nurse, admitting clerk, and the physician at the same time," says Sanchez.

"Our current door-to-doc times are 26-28 minutes," she reports. "With the combination of these processes, we have trimmed off an average of 15-20 minutes."

Sources

For more information about reducing door-to-doctor times, contact:

  • Mary Kate Dilts-Skaggs, RN, MSN, Director of Nursing, Emergency and Outpatient Services, Southern Ohio Medical Center, 1805 27th St., Portsmouth, OH 45662. Telephone: (740) 356-8430. Fax: (740) 356-6387. E-mail: diltsmk@somc.org.
  • Vicki Sanchez, RN, ED Manager, Pomerado Hospital, 15615 Pomerado Road, Poway, CA 92064. Telephone: (858) 613-4328. E-mail: Vicki.Sanchez@pph.org.