Bedside registration working for Iowa ED

Patients and clinicians love the new system

Bedside registration is "the gold standard" for care in the emergency department (ED), ensuring EMTALA compliance as well as patient privacy and satisfaction, says Mary Miller, RN, manager of access services at Mercy Medical Center (MMC) in Sioux City, IA.

Concerned that up-front ED registration could be misconstrued as an effort to obtain financial information before treatment, the hospital implemented bedside registration in July 2000. Also fueling the move was a registration booth design that at the time was not particularly conducive to patient confidentiality, Miller notes.

"Patient satisfaction surveys and comments have shown that patients and their families love it," Miller says. "If a patient has been taken back for treatment and family members are kept out front to give information, they may not care about [the accuracy] of what they give. When [registrars] go to the bedside, patients just love it. They sit there and see that they’re not missing the doctor, and it’s really private because the patient has his or her own room."

"[Bedside registration] has reduced wait time considerably," notes Nancy A. Jackson, MSW, LISW, interim director of revenue cycle systems. "Another [patient satisfier] is that we don’t ask the same questions at three different points." Previously, she adds, patients might have been asked for the same demographic information when they arrived at the triage area, again when they entered the ED, and again if they are admitted to an inpatient unit.

"With bedside registration," Jackson says, "once the information is entered by the registrar, it automatically goes into the computer system. Demographics are pulled up and attached to the nursing assessment, so the nurse doesn’t have to re-ask those questions. It has really reduced the anxiety and frustration on the part of patient and family."

The average ED registration — from the time the patient presents at the front desk to be triaged until the chart prints — takes seven minutes, adds Miller. "If we have had a call and know the name in advance, we can have the chart ready when the patient comes in."

Registration times for all patients have been monitored since the early 1990s, she notes, but the most dramatic improvements have taken place in the past two years. Further enhancing customer service is the ED physicians’ policy of not keeping patients waiting more than 30 minutes, she points out. "Usually, it’s more like 10 minutes."

In another benefit to patient care, Miller says, "the nurse who triages the patient finds a physician immediately and says, This is what’s going on with the patient, this is what I’ve done.’ He can tell [the nurse] to get certain things started."

In other cases, she notes, the nurse may tell the physician that he must see the patient right away. "The physician has a good idea of [the condition of] each patient as quickly as the nurse does."

The registration process works as follows, Miller explains. The patient comes in and is greeted by the triage nurse, who assesses the acuity of the condition and takes the patient back to a treatment room. The nurse goes to a white board located near the nurses’ station and puts an "A" (for access) next to one of the room numbers listed there.

"The registrar, who could be either out front or in the back registering another patient, sees that there is a patient in Room 10 who needs registering," she adds. The ED nurses’ station, Miller notes, is back-to-back with the registration station.

"If the physician comes in and the registrar has to step out, that’s fine," she says. "We’re happy to do it. A lot of the time, the patient is so bad that the physician just says, Stay here and get what you can.’"

Information is entered into the computers in real time and then printed out near the nurses’ station, Miller adds. Registrars take consent forms and copies of patients’ rights and responsibilities, including advance directives, to the bedside as well, she says. "We give [advance directives] to all patients coming through our system, not just inpatients."

At present, registrars make a copy of the patient’s insurance card or ID when they go to the chart room to put the charts together, she notes. "We hope to have a scanner in the future."

When a patient comes from an accident scene, for example, police take billfolds and purses, Miller says, so it can be a long time before registrars get access to patient identification. "We start with a blood bank ID, a red armband with just a number issued by the lab people that is specific to that patient. Any of the lab work or tests that are done will tie in to that number."

There are two registrars on duty for the day and evening shifts, she notes, and one person doing registration from 11 p.m. to 7 a.m.

If the triage nurse has taken another patient back to the treatment area for care and is still there when someone arrives, the registrar out front can either ask the person to wait for a moment or run to the back to get help, depending on the person’s condition, Miller says.

"Sometimes the treatment rooms are full," she adds. In that case, the triage nurse may determine that the person only has a sore throat, for example, and can be interviewed in the registration booth up front. If the condition is more serious, Miller says, the nurse takes the patient back immediately, possibly displacing a nonemergent patient.

"We do have an ambulatory diagnostic area [adjacent to the ED]," she notes, "so we could put a less acute person in there. We have some room to improvise when we need to."

The hospital is extremely committed to compliance with the Emergency Medical Treatment and Labor Act, Miller says, and has an inservice and "skill-builder" session on the subject every year. Registrars are required to score 90% or better on a related questionnaire, she notes.

Staff preparation

To ensure that plenty of staff would be on hand during the learning curve for bedside registration, all the registrars worked 12-hour shifts for the two weeks prior to implementation, Miller says. "Then we would go back and have meetings with the ED nursing staff and the registrars and say, This works and this doesn’t.’"

It was important during that time to have the overlap provided by having three registrars on duty at once, she adds. After a while, Miller notes, the registrar up front, for example, got into the routine of getting the patient’s chart pulled for the registrar working in the back as soon as the printer went off.

Staff also discovered that it worked best if the "front" and "back" registrars are on a one- or two-hour rotation, she says, so each person has a chance to be off her feet periodically.

"One of the things that bothered [the registrars] at first was pushing the carts [containing the laptop computers] around corners and down different halls," Miller notes. Now one is kept sitting in a hallway, shut down and inaccessible if not in use but available when needed, she adds.

The department has four of the carts with laptops, two of which are kept in use and two that are kept in the MIS area being charged and checked, Miller says.

One of the initial hurdles to implementation was nurses’ concern that bedside registration might delay or interfere with care, she notes, but that concern appears to have been alleviated. "Sometimes [nurses] forget to put the patient’s name on the board, so we have to quickly get in there [and do the registration], but that’s just because they’re busy."

Access staff are looking forward to the opportunity to extend bedside registration to some of the hospital’s inpatient areas, notes Jackson. "We have identified the possibility of expanding bedside registration into our Centers of Excellence."

Among several such centers at Mercy, she adds, are a total joint center, a stroke center, a child protection center, and an obstetrics center. "We are one of the top 100 heart hospitals in the country and right now are building a multimillion-dollar heart center."