'Pull to full' speeds up flow
Initiative wins ED recognition
It's always an honor to win an excellence award, but the EDs in the Carolinas Healthcare System that recently were recognized for service excellence under the J.D. Power and Associates Distinguished Hospital Program also can point to specific areas in which they stood out. J.D. Power says it bases the award on five drivers: speed and efficiency; dignity and respect; comfort; information and communication; and emotional support.
Clearly the ED leaders did not sit down one day and say, "We should target dignity and respect," but the ED leaders at Carolinas Medical Center Union, Monroe, NC, say that often initiatives overlapped more than one of these drivers. Missy Baker, RN, BSN, SANE, director of the ED/Clinical Decision Unit, and Thomas Doohan, MD, medical director, emergency services, agree that one recent initiative certainly focused on speed and efficiency, but at the same time improved patient service.
Baker says, "A couple of years ago we were really struggling, and some of us got together and discussed what we could do differently from the nursing standpoint. We implemented a triage bypass process: 'pull to full.'" Basically, she explains, "if you have beds available, you do not keep patients in the triage area. You pull them straight back and do triage in the room." This process is triggered whenever two or more beds are available, Baker says.
"We also implemented standing orders, where the doctors listed specific complaints for which we could get some tests started prior to the doctor seeing the patient," she says.
Another method for improving speed and efficiency involved the development of a spreadsheet that enabled the staff to look at length of stay and patients who left before being seen and break down those numbers by shifts, Baker says. "The charge nurse, the triage nurse, and the physicians that ran the department that day would share the data with the whole facility," says Baker. "We'd look for trends and see if things needed be changed or if we were working well as a team."
One finding from the spreadsheet was that the second shift needed additional providers, she recalls. "We added a physician's assistant on Sunday through Tuesday, our busiest days, and increased the number of nurses on the floor during the second shift from 10 to 12," Baker says.
The department also has addressed lab turnarounds, such as the administration of troponin for chest pain. "We considered the impact of putting point-of-care units in instead of sending out to the lab," Baker says. "We got our time down from 60 minutes to 20."
Patients are 'family'
Doohan says that when it comes to dignity and respect, "I treat patients as I would treat my own family member. And that doesn't only apply to patients, but also to the family members who are in the room."
He also tries to instill that approach in the staff. "This involves personal coaching by myself to the physicians and Missy with the nurses and ancillary staff," Doohan says. "In our meetings, we also encourage the staff to treat people better."
Baker says, "We listen to the patients. They see it as respectful when we do not go in and interrupt, but listen carefully to what their thoughts and feelings are. I think that makes a huge difference."
When it comes to comfort, Doohan says pain management is an important consideration and comes into play most often with chest pain and abdominal pain. Again, he adds, comfort includes family members. "We not only want to make the patient feel more comfortable, but we want the family to feel comfortable that the patient is getting the right treatment," Doohan says.
This comfort level is accomplished in part by setting appropriate expectations, he says. "So, for example, if the patient has appendicitis, we'll tell the family that we have excellent surgeons who can take care of the problem and, hopefully, the patient will be back on their feet in a few days," Doohan says.
Baker says, "We make sure to go over the plan of care with them. We also ask if they have any questions at the end of our interaction. By answering any questions they have, it can allay fears and make them feel more comfortable."
Patient reps give support As part of their ongoing effort to provide patients with emotional comfort, dignity, and respect, the ED at Carolinas Medical Center Union, Monroe, NC, has patient representatives go around to each room and interact with the patients and family. "Sometimes we do not have positive outcomes," notes Thomas Doohan, MD, medical director, emergency services. "We do a really good job of dealing with patients in times of need. We take them to a specific counseling room, and they are catered to by the nurse, physician, and patient representative, who for the most part are at their side throughout the interaction." Missy Baker, RN, BSN, SANE, director of the ED/Clinical Decision Unit, says, "These individuals are trained to handle any stressful situation and to round on patients to make sure we're providing the care they need." While the representatives do not necessarily have counseling degrees, several are chaplains. |
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