Team reduces ED wait times, improves safety

Collaboration nurtures quality improvement

The fast pace of a busy ED can make it difficult to focus in on processes that could be improved, but leadership and commitment can move the needle in the right direction as long as emergency personnel understand why change is important. That, at least, is what Erin Muck, RN, the ED manager and trauma coordinator at Avera Marshall Regional Medical Center, a 25-bed hospital in Marshall, MN, has discovered. The ED treats about 7,200 patients annually, and 100 patients per month are admitted to the hospital from the ED.

When the ED at Avera Marshall began participating in a project aimed at improving throughput times toward the end of 2011, Muck utilized a collaborative process to identify steps that could be improved. Muck asked one of the ED’s four physicians to participate in the effort by attending a monthly meeting in which ideas would be solicited and discussed. She also invited nurses to participate, and she brought in representatives from the lab and radiology departments as needed. Two representatives from the hospital’s quality department participated in the meetings as well.

To make it convenient for the physician to participate, Muck says she always scheduled the meetings during the morning hours when the ED is typically not as busy, generally around 9 a.m. The discussions typically lasted for 30-60 minutes, she explains.

Use data to drive improvement

Over a period of several months, the so-called "quick-hits" meetings produced a number of ideas to shorten wait times for patients while also improving safety. One of the biggest improvements that resulted from the process was a reduction of 12 minutes in the ED’s average decision-to-admit time, bringing this metric from 44 minutes down to 32 minutes. "It was hard to address the decision-to-admit times because a lot of people don’t document them," says Muck. "It took us a good six months just to get that piece of it done."

The "quick hits" team theorized that the admission process could be expedited if the charge nurses were notified earlier on that a patient was likely to be admitted. "That way they could be thinking about who they are going to assign the patient to, what room they are going to open up, and those kinds of things," says Muck. Under this type of arrangement, charge nurses would be able to give the nurses on the inpatient floors a heads-up when they are likely to receive a patient. "It would just give them the time to wrap up whatever they are doing so that they are prepared for an admission," says Muck. Also, the charge nurses would be mentally prepared for a phone call when the decision to admit is made by the physician, she says.

One other reason why Muck felt the approach would work well is because she has a very experienced group of nurses manning the ED. "The nursing staff here average about 24 years of service, so they are very well versed in working the ED and estimating [which patients are likely to be admitted]," she explains. "They do a pretty nice job."

However, when the approach was first implemented, there was snag. "Most of the charge nurses were awesome about this," says Muck, but there was one charge nurse who was not acting on the early information. Consequently, Muck shared a report with the charge nurses showing the decision-to-admit times per charge nurse. "Then she stepped up her game," says Muck.

To sustain the improvement in decision-to-admit times, Muck acknowledges that she needs to keep her eye on it. "If I am not watching that constantly and putting the data out there for [the staff to see], then it is out of sight, out of mind, so then they aren’t doing quite as well," she says.

A similar approach worked well in getting the physicians to pay attention to their throughput times. "Every month I would have a printout of our general throughput times, and then I would have it per physician," says Muck. "Occasionally, I still run those reports. We have some locum physicians [who work in the ED now], so I want to keep track of them and how their throughput times compare with our own physicians. It is a little friendly competition."

Get buy-in

Other ideas that came out of the "quick hits" process include the establishment of a goal for completing the triage process by the time a patient has been in the ED for 10 minutes. Also, blood is now routinely drawn during triage for patients who present with an issue that will likely require blood work, such as patients presenting with abdominal pain, explains Muck. "We figured out how to do triage quicker and better, and these were ideas that we got from the nursing staff, physicians, and sometimes lab or X-ray," she says.

While some organizations might struggle to prevent this type of team-driven process from turning into a blame game, Muck says hospital administrators have nurtured a culture in which it is not OK to get defensive or angry when discussing problems. "We don’t have that problem here. It is always good to get advice," she says. "The managers work well together and we are always open for suggestions. If my suggestion doesn’t work, then they will suggest something different that does."

Muck acknowledges that it can be more difficult to get physicians on board with any type of change. The key, she says, is making sure they understand what the benefits will be of a change in process. She adds that a team-driven approach can facilitate this type of exchange. "In order to problem solve, it is good to have the people involved because you can have better buy-in regarding how to fix things," she says.

While the formal monthly "quick hits" meetings no longer take place, Muck explains that she regularly uses the approach for quality improvement. For example, she is now engaged in an effort to identify ways to improve trauma care. "We have a trauma surgeon involved, trauma physicians, and sometimes orthopedics as well," she says. "Who we invite to the meetings just depends on what issue we are addressing."


Erin Muck, RN, ED Manager and Trauma Coordinator, Avera Marshall Regional Medical Center, Marshall, MN.