Over the past three years, the ED at St. Vincents Medical Center in Bridgeport, Conn., has undergone a complete transformation. From restructuring the 140-person staff to renovating the ED, the Michael J. Daly Center for Emergency and Trauma Care has taken patient and staff satisfaction scores from the single digits to the 90th percentile.
According to Kathleen Woods, RN, MSN, CEN, director of the ED, before the transformation began the ED had a 14% RN vacancy rate, a lack of structure and long wait times. Hired as a change agent in 2007, Woods began the transformation process by following John Kotters theory on leading change. Kotter, a Harvard Business School leadership professor and author, focuses on individual and management support to enact change in the workplace.
Initiating ChangeKathy Gearing, RN, ED staff nurse, left, and Leah Tortora, RN, ED staff nurse, take care of mock patient Larry Davidson, RN, charge nurse, in a new trauma room. Two new trauma rooms are connected by an internal door and can accommodate two patients each if necessary during a disaster.
To create a sense of urgency, Woods evaluated resources and educational opportunities and submitted an action learning project. We had to get rid of the apathy, Woods says.
Her second step was forming a strong staff coalition, which began by having charge nurses and other leaders reapply for their positions to determine if they were the best candidates for their jobs. The new staff comprising new and old employees was selected to ensure 24/7 leadership. To reduce conflicting personalities, a peer-interview committee also was included in the reassignment process.
Woods envisions St. Vincents as a destination hospital with a 0% RN vacancy rate, an ED newsletter, consistent meetings and staff accountability. To get staff buy-in and empower employees to carry out the vision, she started new processes with pilot groups. For example, two RNs and one secretary would try a new patient care process with eight to 10 patients. During the pilot phase, Woods trusted staff to adjust patient care to what worked best, even if it veered from the initial idea, she says.
Nina Fausty, RN, MS, assistant vice president of patient care services, says Woods is effective in getting her staff through each change because through periods of destabilization she is willing to change course if concerns arise. Shes a transformational leader, Fausty says. The change [she has helped create in the ED] has been evidence- and theory-based. Shes a quintessential transformational leader.
The ED also took on new nursing grads who were paired up with preceptors to help assimilate them to the system. The six to seven preceptors take the job seriously, says ED Nurse Manager Joe Halkowicz, RN, who has been with St. Vincents for 35 years. If that person fails, the preceptor feels like he [or she] failed.
Throughout the ED refinement process, employees have been recognized for jobs well-done with money and praise from programs such as Touch My Heart, in which staff and patients hospitalwide write down how staff members affected their lives. Some stories have been so touching theyve brought tears to employees eyes, Halkowicz says.
If we hadnt had the level of commitment across the board, we wouldnt be where we are today, says Dale Danowski, RN, BSN, MBA, vice president of patient care services and chief nursing officer.
Bonuses also were re-evaluated. All managers now get bonuses based on whether they meet their goals, which creates more employee accountability, Danowski says.
In addition, STAT Pack an ED newsletter overseen by Cathy Dokla, RN, BSN provides updates and news on a quarterly basis.
Continuing education and earning higher degrees also are encouraged with incentives, such as tuition reimbursement programs. Because of such efforts, St. Vincents will be at 60% BSN in the next couple of years, Woods said.
Trying New ThingsKathy Gearing, RN, left, says there is more teamwork and communication between nurses with the establishment of the first nurse position. Joe Halkowicz, RN, ED nurse manager, center, concurs. I love ED nursing, Halkowicz says. Its something Ive always enjoyed and it needed some fixing. At right is Ana Brito, ED tech.
After completing phase one of the ED construction, it was decided it would be beneficial to have a nurse assess patients as they check in to reduce ED wait times. This nurse, called the first nurse, is stationed at the front desk. The experienced triage nurses in this role perform a visual assessment and takes the patients vitals to decide if they will be admitted, triaged and discharged, or see a physician quickly.
For example, when patients present with abdominal or chest pain, they are seen by an ED physician and nurse within minutes, says Kathy Gearing, RN, who works in the first nurse role. This type of assessment gets the sicker people care quicker, Gearing says.
Patients with less serious complaints, such as a cold or sore throat, will be sent to the Express Care Plus area to receive treatment. Construction on the area will be completed in August.
A new locked-down unit with six beds was created near the ED for behavioral health patients, which has improved the safety of staff and patients since agitated patients can be directly transferred to that unit. On that unit, one behavioral health nurse and one evaluator provide specialized care.
Gearing says there is much more teamwork and communication between nurses with the establishment of the first nurse position. Overall flow is better and 30% of patients dont make it to the back of the ED, Gearing says, adding nurses and techs have developed stronger bonds with the new process. But staff are not the only fans of this approach. Gearing says patients like the immediate interaction with healthcare staff, and patient satisfaction scores have increased dramatically since the position was implemented in January.
Another useful tool is an eight-hour electronic shift report sent out hospitalwide every morning by Jody Gerard, MD, FACEP, chairman of the ED, that details daily averages, such as door-to-floor times. The physicians, nurses and other staff brainstorm with Woods every morning on how to fix problems immediately. Because of the frequent brainstorming sessions to tweak processes to improve flow, Woods says 85% of patients are seen in less than an hour and the ED has reduced its patient safety events from one per month to one per year.
The ED will triple in size when construction is completed in 2011, Halkowicz says. It will feature 60 beds, an increase of 32 from the original ED. The flow of the ED is continually reworked as newly renovated parts open. The ED serves about 200 patients a day, but Woods predicts that number will rise as baby boomers age and healthcare reform is implemented. When renovations are finished, the ED will encompass 40,000 square feet and will be able to serve 80,000 patients annually. As each construction phase is completed, Fausty says the ED staff carefully measures patient volumes and adjusts staffing according to need.
Other new features of the ED are a four-room triage unit, six new critical care rooms with updated monitoring systems and dialysis compatibility, two connected trauma rooms that can accommodate two patients each if necessary in a disaster, dedicated radiology scanning technology, a new waiting area, a private bereavement suite, new administrative space, a staff locker room, an EMS lounge and a security office.
Coming soon as other phases are completed will be specialized trauma and critical care suites, dedicated OB/GYN rooms, improvements in diagnostic technology, isolation capabilities and a permanent decontamination facility for hazardous spills.
You have to really give credit to the entire [ED] team; its about teamwork, Fausty says. Thats the secret to their success, and I have the utmost respect for them. They are role models.
For information on the transformation of the ED, contact Woods at [email protected]
Editors note: For a photo gallery of the ED, visit www.Nurse.com/gallery/StVincentsED.