"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 adapted from a longer article ED Crowding: What Works? that appeared in the Summer 2009 issue of The Business of Caring.
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