Access Management Quarterly: Use creative thinking to streamline ED patient flow

Program WOWs hospital ED

A dramatic overhaul of the emergency department (ED) process at Paradise Valley Hospital in National City, CA, began with a single question from the director of emergency medicine.

In the midst of an animated discussion of the myriad problems in the facility’s ED — where registrars behind thick glass partitions faced noisy, contentious patients on one side and nurses complaining about tardy face sheets on the other — he asked, "What if we just shut the windows?"

It’s indicative of the outside-the-box thinking of the team that was brainstorming solutions, say Melanie Betancourt, FHFMA, director of patient financial services, and Stephanie Baker, RN, CEN, MBA, director of emergency services, that the answer was not, "We can’t do that."

Instead, Baker adds, the response was another question, "How would we work the process of getting patients triaged and out of the department?"

With that question, she says, the idea of bedside registration was born, along with a project name — Wipe Out Waiting, or WOW.

This six-person core group, which also included the ED admitting supervisor, the admitting manager, and the nursing manager, identified in April 2002 the concepts it would work toward, notes Betancourt.

The team later expanded as needed to include a secretary, nurse educators, registration line staff, and information systems and security personnel, among others.

The representation of security personnel was key, Baker says, because with no glass to protect registrars, security would have to be enhanced.

"Our hospital is in a low socioeconomic area, and the waiting room tended to be wild with people complaining, wanting to get back [to the treatment area] to see family members, and homeless people coming in just to get shelter," she continues.

Other concerns, she adds, included the constant interruption of registration staff, not only by patients’ friends and family, but also by people asking directions to other areas of the hospital, and the need for patient confidentiality, underscored by the Health Insurance Portability and Accountability Act’s privacy standard, which became effective in April 2003.

A crucial issue was the need to accommodate the 5% to 8% increase in patient volume the ED had been experiencing for each of the previous three years, but without adding space, which is limited, Baker says.

The project’s underlying concept, she explains, was to eliminate the typical ED experience of sequential processes interspersed by wait times — the patient signs in, is seen by a triage nurse, goes to the lobby to wait for his or her name to be called to give basic registration information, then sits down and waits to be summoned by a nurse, and so on.

At the outset, Baker explains, the team looked at every segment of time in the ED process, something the hospital already tracked. The segments are as follows:

  • triage to bed;
  • bed to interaction with physician;
  • physician interaction to disposition (a decision on what to do with the patient);
  • disposition to discharge (how long it takes to either admit the patient or send the patient home, for example).

"The cycle time from when patients got to the room to when they got out wasn’t bad," she says, "but the waiting room was where we were losing a lot of time, so reducing triage-to-bed time became our goal. That’s where we decided we could get the biggest bang for the buck."

The WOW project team met weekly, setting short- and long-term goals, and by August 2002, was ready to do a two-week test to see if the concept would work, Baker says. The team presented its plan to the hospital’s senior leadership team, which approved the purchase of three laptops and other equipment, as well as the temporary hiring of additional registrars and security personnel, she adds. "We knew if we were moving to bedside registration, we would have to have laptops and, in a perfect world, would want to have 24-hour security."

Approval came with the condition that the improvements ultimately must be budget-neutral, she says. "We would have to make up the salaries by improving registration, collecting co-pays, getting good financial data, and employing a cash-pay program — but first we had to find out if [the new process] would work."

It was evident right away that the new process was a success, Betancourt says, with triage-to-bed time shortened dramatically. What also was clear when the trial period was over, she notes, was that it would be a mistake to stop the momentum that had been created.

"The core group came back together and said, We have to keep going. If we stop and then try to start again, we’ll have an all-out war on our hands,’" she adds. "We had no idea how painful [the transition] would be. To go through that and then go back to the way it was before wasn’t going to work."

Since the WOW process was implemented, the Paradise Valley ED has shown a 27% reduction in triage-to-bed time, from 45 minutes to 32 minutes, Betancourt says, while point-of-service collections have increased from about $160 per day to about $300 per day.

To put the collection increase in perspective, she says, it’s important to note that that National City has one of the lowest per-capita incomes of any city in California. "In the past, days would go by and not a single copay would be collected."

With the same number of beds, Baker says, the EDs average daily census has increased about 20%, from 84 patients a day in 2001 before WOW was implemented, to 104 at present.

And despite the census increase, Betancourt points out, there has been little or no increase in the number of unfunded accounts. "That tells me we are doing a better job of verification and getting information into the system." The implementation throughout the Adventist Health System, of which Paradise Valley is a part, of the HDX interactive process for eligibility checking has been "very beneficial," she notes, because of the hospital’s high number of Medicare and Medi-Cal (the state’s version of Medicaid) accounts.

When time came to start the new process, Baker says, "we shut the registration windows in the lobby and pushed couches against them," and security guards began 24-hour staffing of a podium in front of the triage booth. What happens now is that the security guard greets people who approach the area, she explains, and asks if they’re there to be seen in the ED or responds to requests for directions — relieving registrars and the triage nurse of those time-consuming tasks.

If the person is an ED patient, he or she fills out a short form that asks for name, date of birth, chief complaint, and time, Baker adds. The triage nurse, who is in a room with a window that protrudes into the waiting area, speaks to the patient, asking what he or she is there for and, if busy with another person, does an "across-room assessment," she says. The nurse then brings the patient in for a "quick triage," lasting no more than two minutes, in which she asks about medications, allergies, and gets vital signs.

In the meantime, Baker adds, the nurse takes the form the patient has filled out, verifies that information, and passes it through an opening into the registration area, where the registrar starts a miniregistration on the patient.

If the patient has been to the hospital before, the account immediately comes up on the computer screen, she adds. If not, a medical record number is assigned.

The patient then moves from triage into the registration area, where the registrar verifies the demographic information and asks the patient to sign the conditions for treatment form. An identifying wristband also is put on the patient at this time, Baker points out, so that, if there is a wait, the nurse can begin any standard procedures she deems necessary, such as a basic lab test.

"It is also a psychological capture’ of the patient," she notes. "If patients are banded early, they are less likely to leave before treatment." And if the patient does leave before treatment, Baker adds, "we could still make a chart, because we have the basic demographics and could call and see how they are."

If a bed is open in the treatment area, the patient goes directly to a room, not back to the lobby, Baker says. "The triage nurse works closely with the charge nurse, using a portable in-house phone, to see which beds are open. The chart follows the patient to the treatment room, where the nurse assigned to that room takes over care.

"This gets the patient to the room quicker and gives the physician the opportunity to get in faster," she adds. "Typically, the physician writes the orders, the nurse initiates the orders, and while waiting for labs or X-rays, the registrar goes in and gets further information from the patient."

While waiting, Baker says, the registrar is verifying insurance and, in the case of unfunded patients, may give the person the appropriate paperwork to apply for Medi-Cal. For unfunded patients who don’t qualify, the hospital has a discount program in place. Because the ED area is completely locked down, there is not a problem with patients leaving after treatment but before discharge, she points out. "We have them all leave through the main entrance, which is where the main registration and triage happens, so there is one more chance for a registrar to talk to the patient if needed."

The only difference in the process in the event of a full house is that the next two patients to receive treatment are put on a couch that is just outside the registration area, Baker explains. "This reminds the staff that there are always people waiting."

If there are more than two people waiting, they do have to go back to the lobby, she says. "We try to give them an estimate [of how long the wait will be], and the triage nurse makes rounds every 15-30 minutes to see if they’re OK. If the patient’s condition changes, they can upgrade as needed."

One of the most striking things about the WOW process, Baker continues, is that it completely changed the dynamic of the ED waiting area. "It’s now calm, well-controlled, and security has taken over the visitor-pass area. [The security guard] has a portable phone to check with the [treatment area], and assigns yellow badges to those who are allowed to go back."

In the past, she notes, a nurse or registrar might open the door for one person, and several more would slip by.

"We also have a better idea at night of who is coming in and out of the facility — we call them visitors, vendors, and violators — and if anyone looks shady, security has time to interact with them," Baker says. "We get very specific notes from patients, saying they appreciate the changes."

Because of the more controlled setting, she adds, "the triage nurse is much quicker and more focused because she is not being interrupted 50 times. She can keep a close eye on the lobby because she is not managing as many people. Most are going [directly] back to a room."

Baker and Betancourt emphasize that the project’s success would not have been possible without a cooperative multidisciplinary team.

"Admitting can’t do it alone," Betancourt stresses. "When we do a presentation for our sister hospitals or other local facilities, we always emphasize that having the integrated team working together is really important."

"We were certainly dependent on the inpatient side," Baker says, noting that the success of the ED operation is tied directly to its ability to get patients admitted in an efficient manner.

Although a bed manager had been hired before the WOW program began, she adds, her role was redefined as a result of the ED initiative. "We did a big push of what it meant and why we were trying to get patients out of the ED so quickly."

"As a team, we were very fortunate," explains Betancourt. "There were no ego problems, no one saying, The physicians don’t want to do it this way.’ Everybody was bringing ideas forth to make sure we were compliant in all areas — particularly with EMTALA [the Emergency Medical Treatment and Labor Act] — and that we would treat patients with respect and protect the hospital."