Kansas Hospital Addresses ED Bottlenecks
Brian Selig, RN, BSN, MHA, CEN, CNA-BC, manager of emergency
services at the University of Kansas Hospital, took a holistic
approach to overhauling patient flow at the medical center’s
Level 1 trauma center, which treats 45,000 patients a year. His
first step: Convene physicians, nurses, and others for a
nine-hour, off-site session to think through patient throughput.
“We literally traced out a patient’s visit from the moment the
patient comes into our doors until the time he or she leaves. We
asked, ‘What is the nurse doing here? What is the doctor doing
here? What’s the process that happens here?’” says Selig.
The group looked for wasteful processes, brainstormed possible
improvement ideas, and spent the next year implementing
activities designed to reduce ED crowding. The results:
Ambulance diversion dropped by 99 percent, the rate of patients
leaving without being seen fell by half, and staff turnover
stopped in its tracks.
Specific ED improvement strategies at the University of Kansas
Hospital included the following.
Empowering nurses to initiate patient care before patients see
the physician. Patients coming to the ED no longer sit for an
hour—or up to three hours during busy times—flipping through old
magazines. “We said, ‘This is wasted time’, so that caused us to
revamp our triage process,” says Selig. “The nurse is initiating
a lot of the care now.”
Selig added a second around-the-clock triage nurse so that
patients in the waiting room could be monitored more closely.
Further, the ED staff worked with physicians to create standing
orders for the 10 most common patient complaints, such as
abdominal pain and extremity injuries. These standing orders
allow nurses to start a patient’s care—for example, sending the
patient for an X-ray or EKG and drawing blood—while the patient
is in the waiting room. A small lab draw station was created
near the waiting room to provide privacy.
“The time that the patient was sitting there and doing nothing
is now value-added time,” says Selig. “This has reduced our
left-without-being-seen rate because the patients perceive that
they’re getting their treatment started.”
Bonus point: Physicians appreciate having more information
about the patient’s condition when they arrive in the exam room
because it allows their work to proceed more efficiently.
Saving nurses—and patients—time. When patient charts were kept
at a centralized rack, nurses wasted lots of time running back
and forth to get their charts or return them to the rack.
Replacing that centralized rack with small, wall-hanging racks
near the nurses’ work stations give nurses easier access to the
charts.
Another timesaver: a new flag system for physician orders.
Previously, nurses were sometimes unaware when physicians had
written new orders for patients. Now small flags are located
outside each exam room; when a new order is written, the
physician positions the flag so a nurse can see from across the
room that the patient is ready to be moved.
Designating some nurses as “team leaders.” Nurses serving in
this newly created position have three overarching
responsibilities: patient throughput, customer service, and
employee satisfaction. “The first job is just helping push
patients through the system—whether that means calling to get a
bed or going to a doctor and saying, ‘Hey, did you know the
X-rays are back for this patient?’” says Selig.
Additionally, team leaders assist nurses in making sure
patients’ needs are taken care of—and make sure that the nurses
are taking care of themselves. “They make sure that everyone
gets their lunch breaks, that they’re not overworked, and that
they have everything they need to take good care of their
patients,” says Selig.
The goal of the team leader concept was to improve patient
throughput while also giving nurses in the department an
opportunity to develop leadership skills. The 15 team leaders
have some clinical shifts and some team leader shifts, in which
they are assigned to assist three nurses but have no patients of
their own.
Increasing capacity. In addition, the medical center increased
its ED nursing staff and added eight new beds to increase
capacity. Together, the improvements have helped patients move
through the ED faster, Selig says, but average ED length of stay
has not declined significantly. “When the hospital is full, no
matter how fast we go, patients are going to stay in the ED,”
says Selig.
Thus, Selig also cochairs an interdisciplinary hospital
throughput team composed of physicians, housekeepers, admitting
personnel, nurse managers, and others who meet monthly to
address the ultimate reasons that the ED gets stacked up. “We
have identified about four or five key areas that we want to
focus our efforts on in terms of improving patient throughput
once they leave the ED and go into the hospital, which will
ultimately help us improve our times in the ED, too,” says
Selig.
This case study is pulled from a longer article “ED Crowding:
What Works?” that appeared in the Summer 2009 issue of The
Business of Caring.
Read the full article.