Patient-centered ED transfers boost safety
Focus on what’s best for the patient
Many EDs have found ways to streamline their triage processes and slash door-to-provider times. Such department-level improvements are important, but eventually ED administrators have to deal with the inpatient side of the equation for those patients who need to be admitted for further treatment. This level of improvement is typically more challenging because it requires active collaboration between the ED and inpatient staff. However, administrators at Hallmark Health, which includes Melrose-Wakefield Hospital in Melrose, MA, and Lawrence Memorial Hospital in Medford, MA, have demonstrated that hospitals can make strides in this area, improving not just patient throughput but patient safety as well.
In June 2012, the two hospitals within the Hallmark system began to implement a new patient-centered transfer process for patients admitted through the ED. Under the new process, inpatient nurses come down to the ED to take reports on newly admitted patients. This transfer takes place at the patient’s bedside in a process that includes the ED care team as well as family members. The inpatient nurse then accompanies the patient up to the inpatient floor.
The approach is part of an ongoing effort at Hallmark to enhance efficiency and quality in the ED while also boosting patient satisfaction. And administrators say it has delivered on all counts. Just six months after implementation, patient satisfaction has increased by at least one full percentage point on Press Ganey surveys. And administrators anticipate that data will soon show that medical errors or omissions have decreased by at least 50%.
Focus on handoffs
The new process followed roughly two years of changes that enabled the Hallmark EDs to reduce patient length of stay by as much as 20%, notes Deb Cronin-Waelde, RN, MSN, ONC, system director of Emergency Services at Hallmark Health. But she emphasizes that the group managing the process was not just focused on throughput. “It wasn’t good enough to just be quick. We also wanted to make sure we were doing things correctly,” she says. “So we used internal data as well as external benchmarking metrics to look at patient safety.”
What became clear, says Cronin-Waelde, is that there were opportunities to improve safety during the critical handoff that takes place when patients in the ED are turned over to inpatient teams.
In particular, the data showed that it is not uncommon for critical information regarding allergies or other aspects of a patient’s medical history to be inadvertently omitted in the transfer process, she says. “The medical history is important to share from one caregiver to the next,” she says. “It is also important that each caregiver knows the actual plan of care in the successive hours.”
For example, a patient who is admitted with a diagnosis of pneumonia needs to have certain things completed at specific times, so communication about the plan of care is vital, says Cronin-Waelde.
The administrators looking at this issue were particularly impressed with the work of Atul Gawande, MD, MPH, a surgeon at Brigham and Women’s Hospital in Boston, MA, who authored The Checklist Manifesto: How to Get Things Right (Picador 2011). In this work, Gawande talks about the use of checklists in many other industries, and how this simple concept can also be leveraged in medicine. For example, Gawande writes about how an airplane never takes off the runway without completing a checklist, and how the same type of process can greatly improve safety in the medical setting, explains Cronin-Waelde.
“We decided to model some of that, so we looked at all of the areas of communication that were important [during a handoff], and then we got a multidisciplinary team together comprised of physicians, nurses, transporters, housekeepers, and anybody who is involved in the touching of a patient and the admitting of a patient to the hospital,” she says. “Everybody had their input.”
The team conducted trials of several different approaches to the ED-to-inpatient transfer process, finally settling on a process that begins with a notification from the ED to an inpatient floor when a patient is expected to require admission. “That is communicated on our tracking board ... so as that process kicks in, the charge nurse assigns the patient to the incoming nurse,” says Cronin-Waelde. “When the patient is ready to depart [from the ED], the inpatient nurse comes down to the ED and receives a bedside handoff, inclusive of the ED nurse, the ED physician provider, the inpatient nurse, and the patient, as well as any family members if they are there with the patient.”
The assembled providers follow a checklist that is sequential in order, going through all of critical information about the patient that needs to be shared. And then there is time for any of the participants to ask questions, adds Cronin-Waelde. “It is a regulatory requirement that people have the ability to ask questions at the end of the encounter,” she says. “This is great because then the patient feels like everyone knows what is going on, and a caregiver or family member has the opportunity to interject information that [the providers] may not know about.”
While the handoff process is working well now, it took time for the providers involved to adapt to the new approach. “Nurses, physicians, and staff are very used to working in particular ways. We have all been trained differently in some ways,” says Cronin-Waelde.
For instance, initially the inpatient staff felt that it would be very difficult for them to leave their floors and their patients to come down to the ED, she explains. “They thought they would be off of their floors for hours, and that this would not take care of their patients,” she says. However, when they tried the process they realized that it actually eliminated a lot of back-end work that they had been doing when they didn’t have all the information they needed about incoming patients. “When you get all the information in real time at the bedside, all of that work goes away,” observes Cronin-Waelde, “so they actually gained time on the inpatient side.”
It also helped that the multidisciplinary team championing these changes took the time to conduct a trial of the reverse of this approach, in which the ED nurses would go up to the inpatient floors to give bedside reports. That approach didn’t work as well because it left the ED physician out of the equation. Ultimately, the inpatient nurses themselves realized that the better process involved having them come down to the ED to take report on the patients, says Cronin-Waelde.
“There are hundreds of nurses, so it is hard to get everyone to really buy in until they have done it a few times and realize how much better the process is,” she explains. “That remains one of the biggest barriers for sure.”
To overcome resistance among inpatient staff, it is important to help them understand how critical it is for the ED to see patients quickly. “The ED waiting room is really the scariest place because even though we triage patients quickly, we really don’t know what is wrong with them until we get hands on and have the providers see them,” says Cronin-Waelde. “So it is a matter of getting the inpatient units to understand that the doors never close in the ED, and that we constantly have an influx of patients. That is our waiting room, but the ED is the inpatient waiting room.”
Inpatient nurses are accustomed to a more controlled environment. Once the beds on the floor are full, and the nurses each have their four or five patients, everything is settled, notes Cronin-Waelde.
Consequently, it can take some time for inpatient staff to appreciate that providers in the ED can’t attend to patients in the waiting room until they “fix the back door” and get patients who are waiting to be admitted upstairs, she says.
Stay focused on the mission
Changing the culture was one of the biggest challenges, according to Steven Sbardella, MD, the system director for the Department of Emergency Medicine at Hallmark Health. “Quite a few of our processes were aligned with our workload and responsibilities. We always would say that we have the patient in the forefront, but in reality we developed systems based on us,” he explains. “We had to let our staff realize that they had to give something up [i.e., control] in order to make the patient the priority in all aspects.”
Ultimately, the professionalism of the staff won out, says Sbardella. “They came to the conclusion themselves after looking at all the value-added data. This was a culture shift.”
Cronin-Waelde’s advice to colleagues who are interested in achieving similar improvements is to take the time to really know the process you have in place before trying to make changes. “Every hospital has different flow models, different challenges, and different processes, so the first thing out of the gate is just to observe,” she says. “Don’t make comments on it, and don’t try to change anything. Just look at it and start to get a feel for where the opportunities are.”
Once you have a firm grasp on the process you have in place, then assemble a team that includes all the players, especially the frontline staff who will have to operationalize any improvements that the team designs, says Cronin-Waelde.
Sbardella advises ED leaders to remember that it will take some time to achieve lasting improvements. “Just keep the mission or mantra up front,” he says. “Is this decision the best for the patient? Just keep bringing it back to that,” he says.
- Deb Cronin-Waelde, RN, MSN, ONC, System Director, Emergency Services, Hallmark Health System, Melrose, MA. Phone: 781-979-3000
- Steven Sbardella, MD, System Director, Department of Emergency Medicine, Hallmark Health System, Melrose, MA. Phone: 781-979-3635