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Unclog the ED Bottleneck

Mary Ann Goodman, RN, left, and Liz Devine, RN

ED overcrowding — sometimes called bottlenecking — is a common problem in EDs across the nation that can lead to a depletion of resources, exhausted staff and low patient satisfaction scores, according to healthcare analysts.To find solutions, the staff at John T. Mather Memorial Hospital, a 248-bed community hospital in Port Jefferson, N.Y., considered the volume of patients at the hospital — 12,000 inpatients and more than 42,000 cases that are treated in the ED annually — and identified three opportunities for improvement — efficiency, patient flow and improved communication.

The first step in the process was the adoption and implementation of a five-level triage system — patients in full cardiac arrest are considered a level one and patients requiring simple wound checks would be classifed as level five. Patients were classified according to how many resources (radiology, labs, consultation with a specialist, etc.) were needed to make a diagnosis.

Part of the process included initiating bedside registration and mini-registration to decompress the waiting area and expedite level one and level two patients examined by the physician. During initial registration, patients entering the ED describe their medical issue to a registrar and provide three pieces of information — name, date of birth and social security number. They are seen by the triage nurse within 10 minutes, and the registrars gather the rest of the information for the medical record after a physician sees the patient. All ambulance patients are triaged at the bedside. Not surprisingly, patient satisfaction rates are high regarding this registration process.
Electronic medical records help to increase efficiency and avoid delays in care. The EMR system presents a real-time snapshot of patients’ status on details such as labs, ECGs and X-rays. The system also prompts physicians, nurses and other staff to complete tasks, which improves patient flow.

The next step was to implement training on the system. “Super users,” staff members trained as coaches, instructed the rest of the team on how to use the computer system. Using train-the-trainer techniques helped the staff buy in to the process. When the go-live date arrived, super users were available to assist on all shifts.

The ED physicians developed 27 first-line order sets — standing orders — to be triggered by the triage nurse to order symptom- or diagnosis-specific testing, which minimizes delays. To further improve patient flow, nursing administration created a bed coordinator position. The bed coordinator is responsible for making rounds to gather information on the hospital’s open beds and communicating with charge nurses on the units and the ED to keep track of admissions, discharges and transfers. She also troubleshoots problems with bed assignments, which frees up nurses’ time for patient care. The ED continues to undergo transformation with the reconstruction of the triage, registrar and lobby areas to improve efficiency.

In tackling the big problem of ED overcrowding, the team has accomplished many of its goals. According to Press Ganey patient satisfaction scores for January 2010, patient satisfaction is currently at 99%. Also, gathered data show bedside registration has decreased the wait time for patients by 45 minutes, while wait time for admitting ED patients has decreased significantly, and employee morale and job satisfaction are on the rise.

By | 2020-04-15T14:34:18-04:00 March 10th, 2010|Categories: Nursing specialties, Specialty|0 Comments

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