Maximize ED Throughput with a Higher-Level Focus on Bed Traffic Control
By Dorothy Brooks
Getting patients seen and treated expeditiously is not only a boon in terms of operational efficiency, it also is a big plus for patient safety. Such factors figured prominently when ED leaders at AdventHealth East Orlando (FL) decided to create a powerful new nursing position to take charge of what they are calling bed traffic control (BTC).
In essence, the nurse leader who serves in the BTC role is responsible for the placement of every patient coming into the ED — a task that requires constant communication with incoming ambulances, triage nurses, and inpatient bed placement personnel.
The BTC position first was implemented as part of a larger ED improvement plan in 2016, producing significant results: The approach helped decrease the median door-to-provider time by a whopping 56.9%, decrease door-to-discharge time by 29.6%, and slash the percentage of patients leaving without being seen by a provider by 73.8%, according to researchers who tracked results from 2015 to 2019.1
The approach proved so effective that the BTC concept has been expanded to all eight of the health system’s hospital-based EDs. Leaders at AdventHealth East Orlando say the approach could work well in other high-volume ED settings, but it requires individuals with the right background and experience to effectively manage such a demanding role.
“We’re using our most skilled asset from a nursing perspective to run bed traffic control because it is a complex job. It requires communication with bed management, all of the nurses on the floor, all of the physicians and EMS as well,” explains Paul O’Brien, MD, an emergency medicine physician at AdventHealth East Orlando and an early champion of the BTC approach.
In addition to making bed placement decisions for all incoming EMS traffic, the BTC nurses organize placement decisions for walk-in patients and communicate with triage to ensure such placements are appropriate. “They also manage all the alerts, from a cardiac arrest to a septic alert or a STEMI [ST-elevation myocardial infarction] alert and, of course, stroke alerts,” notes O’Brien. “It’s a multifactorial job, and what makes it groundbreaking is that it [provides a] constant, 24/7, minute-to-minute, 1,000-foot view of the department which allows everyone else to do very dedicated bedside care in their microenvironment within the department.”
Within a year of implementing the BTC, the hospital went from having what O’Brien refers to as extremely long wait times to being the top performing hospital in the AdventHealth System in terms of throughput metrics. “We have offload times for EMS that are under 15 minutes 99% of the time, which [used to be] unheard of for a large, downtown, quaternary medical center,” he says.
The assistant nurse managers who are trained to perform the BTC role do so on a rotating basis, explains Shelby Mills, MBA-HM, BSN, RN, CEN, a senior nurse manager in the ED at AdventHealth East Orlando. “Our nurses work three [12-hour] shifts per week, and one of those shifts could be in the BTC office,” she explains. “We have five other pods and [the BTC] area is one of their rotations.”
A BTC shift will either run from 7 a.m. to 7 p.m. or from 7 p.m. to 7 a.m. Mills acknowledges that the role can be stressful, but it is a different stress than what the nurses experience when they are handling clinical patient care.
“On a typical 12-hour shift they’re managing this entire emergency department that sees almost 300 patients per day, so they are going from managing medical care [during their other shifts] to working on the analytical, organizational, and operational side,” observes Mills. “Some of the nurses really enjoy [the BTC role] and thrive on being able to see all the moving pieces, and for others, it is their least favorite shift of the week. But it definitely comes with a more organizational kind of stress. You have to be organized to be able to keep everything moving effectively and efficiently.”
The BTC office is positioned directly behind the ED triage area, making it a simple matter for the BTC nurse to communicate in person with the triage nurse, although that is not always the preferred mode of communication. “Our triage nurse has a team of triage techs … and they all have walkie-talkies, and then the triage nurse also has a walkie-talkie,” explains Mills. “In those high-traffic times, it is much easier and faster to just talk over the walkie-talkie … and then the triage techs also know what is going on because they’re on the same walkie-talkie frequency.”
Mills notes if a patient checks into the ED complaining of abdominal pain, the first thing the triage nurse would do is determine whether the patient is eligible for the ED’s fast-track area or requires a higher level of care. At this point, the BTC nurse would designate a specific bed assignment for the patient if a higher level of care is required. Conversely, if the patient can be seen in the fast-track area, then no bed assignment is required. In either case, the patient will be immediately taken to the appropriate bed or section of the ED where he or she will be seen by a provider and undergo any labs, scans or treatment that are required.
If a patient with abdominal pain is being brought to the ED via EMS, Mills notes the BTC nurse will communicate with the EMS team while they are in route and provide a specific bed designation so that EMS can immediately offload the patient to the appropriate room and get back on the road to respond to other calls.
“EMS can rely on us because when they call in directly, they know a lot of the nurses that [serve] in the BTC [role], and they get direct bedding 24/7 no matter how high the capacity issues are within the hospital,” explains O’Brien. “The BTC nurses are able to create beds [when needed] because they understand the dynamics within the hospital, in the front of the ED and what’s going on with the beds in the ED.”
O’Brien states that the BTC nurses can always create space, either by creating pull-beds or holding units. “We have designed the ED to flow,” he says. “It is kind of like a neural network that is centralized within the BTC.”
The ED is organized so that patients are assigned to specific sections based on their level of acuity, explains O’Brien. For example, he notes that patients categorized in triage as Emergency Severity Index (ESI) 4s and 5s (the lower-level acuity patients who do not use a lot of ED resources) are directed by the BTC nurse to a space where they can be seen and discharged quickly.
ESI level 3 patients are sent to a different area that is set up to provide easy access to all the ED resources typically required, such as computed tomography imaging. “All of that is linked to the BTC office so that the nurse there is able to coordinate imaging to help with flow,” notes O’Brien. “If there is a problem, the BTC nurse knows about it and alerts the people who need to know.”
Critical ambulance offload traffic, the ESI 1s and 2s, are directed to another space where there is no holding time, states O’Brien. “It has really reinvigorated our relationship with EMS, and it has led to increased volume from EMS, which is really what we want — more critical patients that this hospital, [a tertiary care center], can serve.”
This type of design facilitates a triple-flow process that enhances throughput, shares O’Brien. “You don’t need that linear queue of people lining up for triage … and then sitting in a chair and waiting to be called back,” he says. “You’ve already built three different areas where they can go.”
In addition to overseeing the placement of patients in the ED, the BTC nurse also plays a role in expediting placement of ED patients who are being admitted into inpatient beds. “That’s where a lot of EDs really struggle. We call it the back door, and what has happened over the last five years is … we have really tried to hardwire the relationship between the BTC nurse and [inpatient] bed management,” states O’Brien.
For example, if a patient has been waiting in the ED for an inpatient bed for an extended period of time, the BTC nurse will communicate with bed placement staff to find out if there is a barrier that can be addressed, shares Mills. “They have to look at those admits every four hours and put in a calculation to get an over-capacity score,” she says, noting that such data go into a report the BTC nurses must prepare.
“They’re looking at how long patients have been [in the ED] since they were admitted, where they are targeted to [be placed in the hospital], and whether we could re-target the patients to a different area in the hospital if possible,” explains Mills. “Also, any ICU request goes through bed traffic control as well, so for a patient to get to the ICU, the clinical team has to let BTC know that an ICU-level of care is required for a patient.” In such a case, the BTC nurse then will reach out to the person in charge of hospital bed placement and they will coordinate this placement together.
The BTC approach has enabled ED leaders to have a real-time understanding of inpatient beds and bed placement and has significantly cut down on the number of holds or patients awaiting inpatient beds in the ED, explains O’Brien. “[Emergency providers] do all of this up-front care, but there is this gap of time for holds which really leads to an increased length-of-stay if patients are not in a proper bed in the hospital, and so that has all been kind of revolutionized by this new process,” he says.
When the BTC process was first implemented, leaders took things day-by-day, tweaking the approach as needed, explains Mills. “As we got comfortable and developed concrete processes, we [documented] what those processes look like, what times of the day BTC nurses need to send reports and what those reports need to include,” she explains.
All the current ED nurse leaders are trained in the BTC role, but whenever a new leader is onboarded, one of the most experienced nurse leaders will take charge of training the new person, shares Mills. “They typically get three 12-hour shifts of training in the BTC position before they are on their own,” she says.
For other EDs interested in potentially implementing a similar approach, Mills advises stakeholders to first consider the kind of volume they’re seeing in the ED. “It may not make sense to do this on a 24/7 basis,” she says. “Some of our smaller campuses have implemented [the BTC position] only from 11 a.m. to 11 p.m. — their high-volume times. For us, it is always pretty much high-volume so we keep it going 24/7. It has been a great process for us.”
Another tip for EDs that are interested in implementing the role is to start the process by just focusing on EMS traffic before expanding it to include the placement of other patients, advises Mills. “That was one of our goals — getting our EMS partners back on the road in a shorter amount of time to deal with other emergencies,” she says. “It was a big early win for us … so I would start there, with your EMS partners.”
What the BTC approach delivers is a higher level of control — the ability to see what is going on throughout the department and to get on top of logjams or other problems quickly, states Mills.
“Everybody jokes with us about [the BTC role], saying it is like having an air traffic controller for an airport, but it’s true,” she says. “As the leader of the department you’ve got all these ‘planes’ coming in from every different direction, and you have to make sure that they’re going to be ‘landing’ in the right spot at the right time.”
O’Brien adds that the BTC nurses impact the front door, EMS, and the back door, and then they also work on patient safety and patient quality because they’re able to continually view the entire department and see where areas in the department are struggling. For example, if there is a test that is not being completed in an expeditious manner, the BTC nurse will reach out to leadership to see what can be done to accelerate the process and move patients through.“[The BTC process] is impacting patient safety [by accelerating] throughput, which allows the physicians and the nurses to really focus on the job in front of them,” he says.
The BTC role was a natural fit for the ED’s throughput and processing goals. Since the approach was implemented in 2016, ED leaders gradually have hooked it into each necessary ancillary service of the department, observes O’Brien. “An emergency department needs the rest of the hospital to survive, so how we link and communicate with the rest of the hospital is what determines our success,” he says. “It is through that node [the BTC] that we’re able to do that, and we’re continually enhancing it and redefining it to allow for continual process improvement within the department.”
- Stahley L, O’Brien PB, Lowe M, et al. The impact of bed traffic control and improved flow process on throughput measures in a metropolitan emergency department. J Emerg Nurs 2020;46:682-692.
Getting patients seen and treated expeditiously is not only a boon in terms of operational efficiency, it also is a big plus for patient safety. Such factors figured prominently when ED leaders at AdventHealth East Orlando decided to create a powerful new nursing position to take charge of what they are calling bed traffic control.
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