Registration process taking too long? If it's more than a minute it is
Iowa hospitals tackle ED wait times with team triage, quick registration
"It's a constant struggle." Reducing door to doc times in the emergency department, that is. And though Iowa has traditionally ranked among the top three states for low ED wait times in Press Ganey reports, it still faces the never-ending challenge all EDs face: managing overcrowding, wait times, and patient satisfaction.
"Maybe across the nation we've been successful," says Jeri Babb, RN, MSN, CCRN, CEN, director of emergency trauma services for Mercy Medical-Des Moines, "but here in Iowa we still have people waiting so that's not OK for us."
Even so, the facility, which hosts the busiest and highest volume ED in the state, has managed to drop its door to doc time by half. Before the "quick reg" process was implemented in August 2006, the average door to doctor time in the 44-bed ED was 72 minutes. With the new registration policy, that time dropped to 36 minutes.
Using Six Sigma methodology, a multidisciplinary team at Mercy "started to look at throughput," Babb recalls, "because, after all, that is what makes or breaks wait times." The group took the example of a patient presenting with abdominal pain and drilled down to uncover ways to cut the time to "getting patients to treatment, because what the patient cares about is their pain relief, how soon before they see a doctor," Babb says. And since "you can't initiate care until that patient is in the system with an ID number," the quick registration process seemed to answer that need.
When an ambulatory patient walks into Mercy's emergency department, he or she encounters a triage desk, where a team comprising a nurse, a registration clerk, and a tech is stationed. The team works together to check the patient in. As the registrar obtains the four criteria needed for registration name, date of birth, Social Security number, and the name of a family doctor if appropriate the nurse can quickly assess the person, asking him or her why they need to be seen. In the meantime, if the patient needs a wheelchair, the tech can grab one and after the four-part registration is completed, can wheel the patient to a triage room where a brief assessment is done. Only after the nurse and physician treat the patient in the treatment room is the entire registration completed with address, insurance information, etc. by another registration clerk.
With the abdominal pain patient, once the registration clerk enters his or her information into the computer, an ID band is printed, and the patient is immediately assigned a patient number. "The [traditional] registration in and of itself can take five minutes or so," Babb says. "Some patients can't wait that long. So we do this quick reg, and it also tells the patient, 'You know what? We're most interested in you and your condition, not in your payment and not in your status that way.' It's been extremely well received by patients. A lot of people at the front desk still say, 'Here's my insurance card.' And we tell them, 'They'll ask for that later. We don't want to see it now.' It gives the right message."
Once the patient goes through quick reg, he is taken to a triage room where he is assessed further and then taken to a treatment room, if one is available, or to the waiting room if all beds are full. That patient in the waiting room has been triaged, had his or her vital signs taken, and has a patient ID. "In our ED and in most EDs, you can't do anything [such as give medicine, order lab work, or complete X-rays] until the patient is registered," Babb emphasizes.
When patients with acute needs such as those who appear to be in extreme distress, can't breathe, or are experiencing chest pain or patients arriving in an ambulance come in, they bypass the initial triage desk and are escorted directly to a treatment room, where the quick reg process is completed at the bedside. Once the patient's name, Social Security, date of birth, and family doctor's name is collected, the nurse can immediately begin treatment.
Teamwork integral
Babb credits teamwork for their success. "As long as you have a registration clerk doing their own thing, and the nurse doing their own thing, and the doctor doing their own thing, that meant wait time for the patient. So if we group these people into teams that get to the patient all at the same time, it means things get started sooner."
For each 10 rooms in the ED, also referred to as pods by internal staff, there is one physician, three nurses, a registration clerk, and a tech. As patients come in, the pods are rotated for placement, with the registration clerks taking direction from the nurses and the physicians.
The nurse greeting the patients along with the registration clerk evaluates patients with a five-level classification system. In decreasing order, those are: resuscitation, emergent, urgent, semi-urgent, non-urgent. With levels 1 and 2, patients are taken immediately to a treatment room, where the quick reg is done at the bedside. Since the registrar works alongside a nurse, that information is communicated up front.
Babb works closely with Mercy's director of admitting. "That's key for better patient care," she says working to eliminate silos; working together "even if you don't report to the same person;" and working to answer the question, "what would be best for the patient?"
Another Iowa hospital's story
St. Luke's Hospital in Cedar Rapids has used the quick registration process for about four years, with positive results, and like Mercy is undergoing new construction of the emergency department. It's added a second triage room and its 24-bed ED will hold 10 more beds when construction is complete in December. Mercy is moving toward universal rooms "which means everybody can be treated in any room," Babb says as part of its redesign.
Also like Mercy, St. Luke's emphasizes hastening the traditional registration and triage process, while focusing on providing constant communication between patients and staff. Sandi McIntosh, RN, MA, CNA, director of emergency services, says the hospital has hired four guest relations employees and staffs them from 9 a.m. to 1:30 a.m., to capture peak hours, seven days a week.
Their primary goal, McIntosh says, is to meet and greet, "rounding" through the ED to provide patients updates, asking them how they are doing, as well as providing drinks or whatever patients might want and directions to hospital sites including the bathrooms. They check in with patients about every 15 minutes.
The hospital also staffs volunteers or guest relations personnel at another entrance used for general traffic to direct them to the ED. McIntosh says the hospitals holds a "no point" policy, meaning no staff member will point out a location to patients but rather will show them where they are supposed to go. As patients enter the ED, the guest relations staff ask the patient, "Are you here to see a physician?" and then directs them to the appropriate place.
The hospital's registration staff, which report to patient access, "had to go through the learning curve" to adopt the quick registration process. "It works," McIntosh says. Their ultimate goal is to have every patient go directly to a room, bypassing the traditional registration process altogether.
ED bed huddles are held twice a week on Mondays and Thursdays. Attendants include the patient flow coordinator and representatives from the medical/surgical unit, staffing, critical care, housekeeping, and the ED. There they discuss bed availability, staffing, the patient census, and discharges. The plan is transferred to a spreadsheet after the meeting and circulated to the managers of each department. "Emergency bed huddles" are scheduled when a staff member calls the operator and the message is sent to designated pagers of critical staff members.
"It's a constant struggle." Reducing door to doc times in the emergency department, that is. And though Iowa has traditionally ranked among the top three states for low ED wait times in Press Ganey reports, it still faces the never-ending challenge all EDs face: managing overcrowding, wait times, and patient satisfaction.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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