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High diversion rates. A national nursing shortage. Increased patient volumes. Unfortunately, these are the major trends that will challenge your ED for some time to come, predicts Michael Williams, president of the Abaris Group, a Walnut Creek, CA-based consulting firm specializing in emergency services.
You must be proactive in addressing these trends, urges Williams. "I am a firm believer in better and best practices and learning from our peers. At a minimum, sign up for the Internet ED manager listservs and engage in the dialogue," he says. (See "Resources" at end of article for information about joining listservs.)
Improve the tools you "bring to the table" by attending national conferences on better and new practices, says Williams. He points to the lack of a nationwide best practice coalition for ED managers to discuss and publish long-term solutions. "One does not exist and is desperately needed," he asserts. Here are several short and long-term ED management trends and how you can address them:
• High diversion rates. Diversion is a major problem in most EDs, especially during peak volume season, says Kim Colonnelli, RN, BSN, MA, director of emergency and trauma services at Palomar Medical Center in Escondido, CA. "The old standard, when everybody’s closed, everybody’s open,’ doesn’t work anymore," she stresses. Hospitals cannot solve this dangerous problem alone, says Colonnelli. "Diversion is a problem that must be shared by all parties, including EMS agencies and county authorities," she notes. "We must work together to find solutions."
• Increased patient volumes. To confront this problem, implement "best practices" for ED staffing, says Williams, who says he has his own proprietary source from his studies that he is willing to share. (To contact Williams, see "Sources" at end of article.) You should also use information and tracking systems, both hardware and Internet-based, recommends Williams. "The most important thing for these systems to accomplish is real time data on patient status and their activities in the ED," he adds. "Consider alternative product lines to assist with this, such as rapid admission units, clinical decision units, and fast tracks."
To combat overcrowding, use technology to improve patient flow and inpatient processes, advises Williams. "Many managers are attempting to learn more about how to move patients through the ED and hospital," he says. For example, patient-tracking systems is one of the most effective tools for improving ED processes, says Williams. "However, they are expensive and difficult to sell to administration," he acknowledges. "There are similar inpatient and bed-tracking systems that are extraordinarily helpful to improving hospital inpatient capacity." They are generally cheaper as the inpatient versions are usually add-ons to other systems such as patient documentation and clinical programs, says Williams. "The return on investment is phenomenal, though, if the processes are in place to make optimal use of the tracking system," he says.
Learning more about these systems will go a long way for the "sell" to administration, says Williams. "Having sufficient dollars in place, with proper charging, APC coding, and billing/collections, to help fund such systems is also effective," he says.
• Shortage of on-call consultants. A shortage of on-call medical staff is a burden in many urban EDs, reports Williams. "It is now apparent that this problem is not all about money," he says. "We must create innovative protocols and resources, such as hospitalists, to assist in reducing this burden."
Technology will be of some assistance, says Williams. "Information systems can be used to better define the needs and problems in responding to on-call needs," he adds. For example, these systems can tell you when on-call requests occur and what the response time is, says Williams. "You can also find out if it’s commensurate with the patient’s needs or is at the convenience of the on-call physician, such as on-call specialists that won’t come in until their office practice is closed for the day," he notes.
• Lack of qualified nurses. Clearly, the nursing shortage will be with us for a long time, says Williams. "Some experts are saying that we will not even feel its full force for another five to eight years," he notes. "We must be a lot smarter and innovative about how we use nurses. Do we really need to have nurses do all they are doing? If not, the use of other care partners should be considered."
It appears the original goal of a "100 percent RN" ED is no longer sustainable, Williams says. "Our recommended mix is 60% nurses and 40% support staff," he reports. Provide them with a better working environment, Williams advises. Increasing volumes and acuity with inadequate staffing, long turnarounds, and angry patients is the exact opposite of an environment that’s attractive to nurses, he says. "Changing processes can help make the ED a much more attractive place for nurses," Williams adds.
Due to the decreased number of students in accredited nursing programs, you’ll face an uphill battle in staffing your ED with qualified nurses, warns Colonnelli. "Our training ground’ has always been the medical/surgical areas. Those nurses go to the CCU [critical care unit ] or ICU [intensive care unit], and transfer to the ED," she says. "That is not happening anymore."
In response, many EDs have implemented programs to train new graduates, she notes. There is also a trend toward cross-training staff from telemetry or ICU, says Colonnelli. "At our facility, we have a very successful program where we cross-train a group of nurses who work in a cluster of units: the ED, CCU, telemetry and intermediate care [IMC]," she reports. "Based on staffing needs for each shift, they can be sent to any one of those four units."
ED nurse managers at Portsmouth-based Southern Ohio Medical Center, support a "cut-and-paste" schedule, says Mary Kate Dilts, RN, MSN, director of nursing, emergency, and outpatient services. "This has been a recruitment and retention tool for our ED," she says. "We have a lot of staff in school and are willing to change the work schedule for their benefit."
For more information about trends in ED management, contact:
• Kim Colonnelli, RN, BSN, MA, Emergency and Trauma Services, Palomar Medical Center, 555 E. Valley Parkway, Escondido, CA 92025. Telephone: (760) 739-3320. Fax: (760) 739-3121. E-mail: Kim.Colonnelli@pphs.org.
• Mary Kate Dilts, RN, MSN, Emergency Department, Southern Ohio Medical Center, 1805 27th St., Portsmouth, OH 45662. Telephone: (740) 356-8430. E-mail: firstname.lastname@example.org.
• Michael Williams, The Abaris Group, 700 Ygnacio Valley Road, Suite 250, Walnut Creek, CA 94596. Telephone: (925) 933-0911. Fax: (925) 946-0911. E-mail: email@example.com.
Here are two listservs pertaining to emergency medicine and information on how to subscribe to each:
• Pediatric Emergency Medicine. This list focuses on the care of ill and injured children in the ED. To subscribe, go to the web site PED-EM-L@listserv.brown.edu, click on "mailing list archives and subscription management" and then "PED-EM-L" and then "join or leave the list."
• Emergency Nursing World. Send an e-mail to LISTSERV@ITSSRV1.UCSF.EDU with message "subscribe Em-Nsg-L [type your name here].