Critical Path Network
Busy ED keeps promise of 'door to doc' in 31 minutes
Streamlined processes involve thinking outside the box
Gilbert (AZ) Hospital has one of the busiest emergency departments in the area and an average ED waiting time of less than 12 minutes.
The 23-bed emergency department treated more than 51,000 patients in 2007 and met its commitment 98.3% of the time to get patients from "door to doc" in 31 minutes.
"Our commitment is to see our patients in a timely and efficient manner and to be able to provide the same quality of care in a shorter time frame. It's not that we are providing less care. It's just a matter of thinking out of the box," says Carolyn Masood, RN, director of quality management and performance improvement.
Gilbert Hospital opened in February 2006. The fact that it was a new hospital gave the staff an opportunity to create an emergency department designed for prompt and efficient care and streamlined treatment process, Masood says.
"We threw all the traditional red tape and micromanagement out the window. We base what we do on what is best for the patients as guided by state and federal guidelines and regulations. It's just all done in a different way, in an out-of-the-box manner, rather than the traditional way. And it works. In a recent week, the average waiting time was 11 minutes," she says.
Hastening the transfer process
Because the hospital is small and transfers a lot of its patients who require additional services to other facilities, Gilbert instituted measures to speed the transfer process and ensure that it goes smoothly. Among those are locating ground and air ambulances on site, eliminating the wait for transportation for transferring patients, using equipment that can transfer easily into ambulances, and following up with receiving facilities to ensure that they have the information they need on transferred patients.
Other initiatives include frequent communication between staff in the emergency department and the other patient areas, constant monitoring of patient flow in every hospital department, regular meetings to analyze where breakdowns occurred, and staffing for peak volume 100% of the time, Masood says.
'Constant awareness'
The emergency department is structured so that the triage nurses can see in to the waiting room and make the physicians aware that there is a patient waiting.
"There is a constant awareness of how many patients are in the waiting room. The registration staff communicate constantly with the charge nurse and the physicians in the emergency department. They notify the physicians how many patients we have waiting and when they entered the emergency room," Masood says.
The emergency department team monitors the time that patients are in the emergency department and communicates with the patients who are waiting.
"We let the patient know what is going on if they have been waiting longer than usual. It's waiting and not knowing why that causes frustration. When we communicate with those who are waiting, they're usually very understanding," she says.
Whenever possible, the hospital completes the full registration process at the bedside.
"We don't want patients to have to spend 15 minutes waiting to get registered. When they walk in the door, the registration department takes their name and takes the vital information for their armband. Our goal is, if we have a bed open in the back, that's where they go," she says.
The hospital's goal is to treat all patients as an emergency and see them as quickly as possible.
"With our caseload, we try to see patients in the order in which they arrive. However, acuity levels of each patient will also determine when they are seen. If a patient comes here, we treat it as an emergency and begin treatment as soon as we possibly can," Masood says.
Communication integral
Communication between the emergency department staff and the nurses on the floor is an important part of moving patients quickly through the continuum, says DeNage Cagle, LPN, the hospital's case manager.
Cagle is a crucial part of the process because the hospital is so small and the emergency department utilization is so high, Masood says.
"Because we have a small number of inpatient beds compared to other hospitals, it is critical that we move our patient either to our inpatient unit or to transfer them to a receiving facility as rapidly as possible," she says.
Cagle is responsible for coordinating care and discharges for all the inpatients and the emergency room patients with complex needs.
"The emergency room nurse handles the routine discharges but calls me if there is a difficult situation such as patients with Medicare who don't meet admission criteria but who can't be discharged safely to home," she says.
Cagle is the link between the emergency department and its pending admissions and the treatment team and who might be ready for discharge.
When she comes in each morning, Cagle reviews the charts of all the patients, determines which patients are clinically ready to be discharged, and works with the physicians and treatment team to make sure that the discharge preparations are being made.
"I work as a team with the physicians, the nurse caring for the patient, the charge nurse, and the unit secretary to facilitate discharge and the transfer process," she says.
Masood meets with department heads each morning and reviews the waiting times and the percentage of success in meeting the goal the previous day.
If there was a delay, the team drills down to determine why it occurred. The hospital's electronic medical record has the ability to run queries to evaluate response times and patient flow through each department.
Whenever there is a breakdown in the patient flow process, Masood meets with the people involved either that day or the following day to analyze what happened.
They determine where the delays occurred and brainstorm on how to avoid the same thing happening in the future.
"If a patient waits 40 minutes to see a doctor, we take that very seriously. We analyze every department involved to determine what happened. Forty minutes may not sound like a long time, compared to the Arizona statewide average emergency room wait time of five hours and 37 minutes, but it's too long for us," she says.
The team dissects every step of the process to determine what is working and what is not working.
In some cases, it's a matter of needing more personnel or equipment, she says. In other cases, it's something beyond the hospital's control.
For instance, if the hospital and emergency department beds are full of patients with high acuity levels who need more intensive care for longer periods of time, the hospital can't safely discharge them and the emergency department may slow down a little.
"We evaluate times when the volume is high as well as seasonally when the acuity is higher so we can have adequate staffing. When we have a breakdown, the volume and acuity of patients is one thing we analyze," she adds.
Transfer contract
When patients have to be transferred to other facilities, the process is quick because the hospital has contracts with ground emergency medical services and is an air ambulance base station.
The equipment in the building is designed to make transfer to an ambulance or helicopter quick and easy. The patients are transferred from their bed to a gurney, bringing their monitors and IV poles with them.
"We don't have to wait for transportation, and the patient monitors don't have to be unplugged and replugged to fit into the helicopter or ambulance. It makes the transfer process very rapid," she adds.
In order to maintain a good relationship with the receiving facilities, the hospital's director of consumer affairs, Frank J. Frassetto, follows up in person within 24 hours whenever patients are transferred to another hospital. Sometimes he visits other hospitals as much as 15 times a day.
He meets with the receiving physician or nurse to find out how smoothly the transfer went, if the patient's clinical condition on arrival was what was originally communicated, and if the hospital received all the information it needed.
"We developed this project because we send so many patients to receiving facilities and we want to ensure a smooth and flawless continuum of care for the patients. We follow up on 100% of the transfers," Masood says.
If the facilities need additional information from the medical records, Frassetto can access the data, print them out on site, and get them to facilities quickly.
The hospital's physical layout and processes are designed for efficiency but the mindset of the staff is also an essential part of rapid and safe patient throughput, Masood says.
From the day the hospital opened, the entire hospital staff — from registration to nursing to ancillary departments and physicians — have worked toward the goal of seeing patients promptly and efficiently, she adds.
Gilbert (AZ) Hospital has one of the busiest emergency departments in the area and an average ED waiting time of less than 12 minutes.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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