While delays in obtaining ED care have become common, hospitals are taking steps to speed throughput and improve services.
We dont want people waiting in our waiting rooms, says Mary Jo Stark, RN, MS, CEN, emergency services nursing director at Peconic Bay Medical Center in Riverhead, N.Y. Its not good for patients. Its not good for business. Its a big patient dissatisfier, and its dangerous.
The U.S. General Accountability Office reports that emergent patients those who needed to be seen within 14 minutes waited an average of 37 minutes for care in 2006. The Centers for Disease Control and Prevention National Center for Health Statistics indicates there were 199.2 million visits to hospital EDs that year, with demand growing steadily since 1996 at about 3.2% a year.Maryann McLaughlin, RN
Hospitals have attacked the complex wait-time problem by establishing multidisciplinary teams and securing leadership support. Northern Westchester Hospital in Mount Kisco, N.Y., spent nine months reviewing and overhauling its processes. Holy Name Medical Center in Teaneck, N.J., also analyzed the entire process and fostered a culture change. Now everyone in the facility shares responsibility for throughput.
Its a lot of small process changes that help the big picture, says Maryann McLaughlin, RN, CEN, unit director of the ED at Holy Name.
Improving ArrivalsCathy Cioffi, RN
Collaboration with emergency medical services has helped some facilities improve wait times. Englewood (N.J.) Hospital and Medical Center has given EMS companies the charge nurses phone number. She assigns a room, and EMS takes the patient directly to that bed, says Terry Bertolotti, RN, MSN, CEN, patient care director of the Englewood ED.
Newark (N.J.) Beth Israel Medical Center has placed a well-seasoned greeter nurse in the waiting room to manage waiting patients, reassess patients as needed and place those needing immediate care into the treatment area.
The first day we had the greeter nurse, we picked up a 48-year-old patient having a silent MI, says Mairead ORegan, RN, administrative director for the ED and logistics department at Newark Beth Israel. It was only because there was a clinical person there, drilling down with questions, that we were able to pick that up.Nancy Kostel-Donlon, RN
St. Francis Hospital in Roslyn, N.Y., has placed a security greeter in the waiting room to note arrival time, and it benchmarks to that time. Care managers at the hospital address placement and social issues and call the teams attention to those problems during daily meetings.
The focus is on the patient experience, says Nancy Kostel-Donlon, RN, MSN, CCRN, CEN, CPAN, BC, nurse manager of the ED at St. Francis. We practice a relationship-based care model.
At Peconic Bay Medical Center, nurses bring patients directly back into the ED and triage them in the bed. That cuts off the front-end experience, which can be a bottleneck, Stark says.
Nurses at Holy Name, St. Francis, Northern Westchester and Englewood complete a quick triage, obtaining the patient complaint and vital signs and performing a short assessment before taking the patient to a bed, if one is available. The primary nurse completes the assessment and medical history once the patient is in a room.
Northern Westchester created a flow coordinator position to assign patients and monitor flow and the status of labs and imaging studies. Actions take place simultaneously, with improved communication among staff. Patients flow through much quicker, says Cathy Cioffi, RN, CEN, manager of the ED at Northern Westchester. Everybody is held to task.
Fast-Track & Special PodsTerry Bertolotti, RN
Fast-track units speed through less-acute, treat-and-release patients, such as those with sore throats, earaches, broken wrists and other minor problems, so they no longer get bumped for a cardiac arrest or other acute emergency. Turnaround time at Peconic Bays prompt care unit has decreased to less than two hours on average. Holy Name also has established a pediatric pod, with a pediatrician on staff during hours when it treats the most children. At Newark Beth Israel, a nurse practitioner evaluates and treats fast-track patients. Once discharged, the hospital refers them to a community clinic. It has decreased the return rate of patients who seek care for nonacute problems.
ED throughput represents a house-wide issue. Emergency patients cannot move to a floor if no beds are available. They continue to occupy an ED stretcher and hold up other patients.
Peconic Bay conducts a bed-huddle, with all nurse managers, if it appears the hospital will not discharge enough patients to make way for new ones. Occasionally, it will open a relief unit, staffed by float nurses, Stark says.
New York Methodist Hospital in Brooklyn, N.Y., opens a temporary unit as an overflow. Nurse manager Christopher Bennett, RN, BSN, collaborates with the ICU to ensure faster transfers. The goal is to move patients to an inpatient bed within an hour.
Newark Beth Israel has placed ORegan in operational control of all hospital beds to improve patient placement. Special teams respond to septic and myocardial infarction patients.
Englewood uses an electronic recording system to give a verbal report to nurses on the floor. The admitting nurse receives a text message from the bed assignment system.
Patients do not leave the Northern Westchester ED until their lab results are back and antibiotics or other prescribed drugs initiated. The hospital monitors processes and holds staff accountable for completing tasks on time.
Its all about the patient and getting them where they want to be out of the emergency room quickly, all the while maintaining a high standard of care, Cioffi says.