EXECUTIVE SUMMARY
To deal with surging volumes and long wait times, some EDs are finding success with techniques that optimize resources, facilitate communications, and speed decision making. These include the use of a bed czar as well as software programs to keep upper management focused on patient flow metrics. Other approaches include placing mid-level providers in triage to speed decision making and eliminate communications gaps.
- Sharp Grossmont Hospital in La Mesa, CA, has been able to slash both diversion hours and wait times by implementing a bed czar, adding a nurse practitioner to triage, and developing new codes to bring on extra help when ED volume surges. The hospital also is working with post-acute care partners in the region to reduce unnecessary repeat visits and ensure care is in alignment with patient wishes.
- Bothwell Regional Health Center in Sedalia, MO, has been able to slash wait times by replacing a phone communication-based system with radio headsets so the entire nursing staff is notified when a new patient presents or any nurse needs assistance. The approach has trimmed three minutes off door-to-ECG times for chest pain patients and has delivered security benefits.
With more than 300 patients presenting for care every day, the ED at Sharp Grossmont Hospital in La Mesa, CA, is one of the busiest in the region, and the surging volume has taken a toll. In recent years, the ED has been forced to go on diversion as much as 50% of the time, and wait times to see a provider often have exceeded two hours. However, during the past 18 months administrators have had some success boosting capacity and efficiency. Although this work continues, diversion hours have been reduced drastically and wait times have been cut in half.
This progress has not been the result of any one intervention, but rather of a series of steps that have had the effect of expediting patients through the ED without compromising safety, explains Scott Evans, PharmD, MHA, the hospital’s senior vice president and chief executive officer. For example, Evans notes that the medical group the hospital contracts with to provide emergency services has added a physician extender, usually a nurse practitioner (NP), to the triage process to expedite decision making, and in some cases, actually deliver treatment to patients with low-acuity medical concerns.
“These are providers that patients can see generally within 20 minutes of registering in the ED,” Evans explains. “The patients go through the full medical screening because that is required of all our patients to make sure we are not missing anything and to see what needs they have.”
Some of these patients will present with a bump or a bruise that needs attention; others may require a prescription for an antibiotic or some other medicine.
“The NP can take care of those lower-acuity things, and then help escalate the higher-acuity matters to the physicians and move those patients back into the ED more quickly to be seen,” Evans says. “The NPs work under a physician, but can handle certain problems right there and then.”
In addition to adding an NP to triage, the hospital has enhanced its fast-track service, providing designated space and operating hours to provide care to lower-acuity patients within the ED. Evans notes that the fast-track service used to be embedded as part of triage.
“It is more of a program now, and it has its own space where people can be seen,” he says.
Tightly Manage Bed Utilization
To optimize resource use, the hospital added a new position for a registered nurse (RN) to serve as a “bed czar.”
“This is generally someone who has a good house-wide understanding of patient flow as well as some stronger critical and emergency care skills,” Evans notes.
The bed czar focuses on making sure that patients awaiting inpatient beds are moved to an appropriate open bed as quickly as possible while also keeping an eye on other resource needs. For example, Evans notes that a good bed czar would know to preserve an open bed on the stroke unit for a patient who is on the way to the hospital with a code stroke.
“There may be three other patients in our ED that could be admitted to that stroke unit; they would not necessarily be having strokes, but they could be cared for in that level of care,” Evans observes. “The bed czar will make sure that these patients are moved to the right areas so that when the stroke patient comes in, we can move him right to the stroke unit.”
The bed czar helps adjust resource utilization based on acuity, disease state, and open beds, Evans explains.
“He or she can juggle all of those things to try to maintain the best patient flow, and then all of those metrics are tracked for us so that we know if we are getting better,” he says. “For example, the time that a patient is in the ED and ready to move to the time [the patient] is actually moved — we track that metric continuously.”
The success of utilizing a bed czar is highly dependent on the person picked to serve in that role, Evans advises.
“Person A might be better than person B at being the bed czar, so you have to figure out what the skill set is and refine that,” he says. “Then it is [a matter of] constantly going back and talking to the staff about what is working and what is not working.”
Keep Higher-ups in the Loop
To ensure upper management is kept abreast of key patient flow metrics, Evans has implemented software that regularly reports these figures.
“If there are barriers to performing, we want the executive team to be aware of those barriers to help knock them out,” he explains. “If we are having a resource issue of some sort, we can help coordinate resources across the organization and bring them into the area where they are most needed.”
Such metrics are automatically reported to executives every six hours, and these reports are rich with information, Evans explains. For example, he recalls one report that indicated that four patients in the ED were ready to be moved upstairs, but none of those patients had been assigned beds.
“[The software program] cross-referenced [the patients] to open beds inside the facility, and you could see that there were more than four open and staffed beds in the patients’ [needed] level of care,” he explains. “That helps us facilitate a dialogue the next morning. We have entity huddles where we get together and discuss why we were slow in moving those patients up.”
The regular reports create an awareness and an expectation that patients need to be placed in the right level of care as quickly as possible, Evans observes.
“That helps with accountability,” he says. “We are all seeing the same things, and we are also then understanding the situations that are going on in the hospital better.”
Work with Partners
One new effort underway at Sharp Grossmont involves working more closely with skilled nursing facilities (SNF) in the region.
“The ED issues actually start upstairs in the hospital when patients are first placed in the skilled nursing facilities,” Evans says. “What we were finding was that essentially patients would be coming back to us, and the plan of care would no longer necessarily be the same, or [care providers] would not be following the same plan of care in terms of looking at things like advanced illness management.”
For example, Evans notes that a patient with advanced, metastasized cancer and a do-not-resuscitate (DNR) order might be brought into the ED with an acute myocardial infarction, and there would be a lack of clarity on what type of care was most appropriate for this patient. Such a patient might be taken to the catheterization lab, and then wind up receiving open heart surgery.
“Is that really what [the patient] wanted? That is where our work with the SNFs comes in,” Evans notes. “We want to make sure we are aligned with our partners in our post-acute facilities to make sure we are doing what is best for each particular patient.”
Further, Evans notes that hospital administrators are considering a pilot program that would involve the hospital actually sending out care teams to some of the SNFs when they have a patient who requires a consultation, rather than bringing the patient to the ED. Some of the hospital medicine providers already are picking up contracts as extensionists in the SNFs so that the hospital and the SNFs are aligned on the plan of care, and the plan of care becomes more consistent and aligned with what the patient asked for, Evans explains.
Leverage Frontline Staff
To address the high number of diversion hours, the hospital has developed a number of codes so that when the ED rises to certain levels of activity, the codes trigger action.
“People will come together and try to identify resources that will help with the immediate capacity issues that ultimately will hopefully keep us off of diversion and able to still take care of our patients in the ED,” Evans says. “To that end, we have very significantly reduced diversion hours over the last year, but we are balancing that with making sure that we are not having extensive offload delays because it is one thing to just say you are not on diversion, but if you have six ambulances and they are waiting for 45 minutes to offload patients, that is not necessarily a good thing for patient care.”
The hospital has been able to reduce diversion hours while not increasing offload delays, but the problem isn’t solved yet, Evans notes. Administrators are evaluating whether further progress could be made by activating extra resources earlier, focusing resources differently, or further optimizing the algorithms the hospital uses to manage capacity.
Evans acknowledges that making all these changes is stressful on the organization, but that staff members are encouraged by the results.
“I think what is working for us ultimately is partnership with the physician group working in the ED as well as bringing in frontline staff to do problem solving,” he says. “They were the ones who said if we had a person who could help flow patients a certain way, that would be helpful, and that is how the bed czar role was created.”
Evans notes that Sharp Grossmont has a Lean Six Sigma department that uses the management philosophy’s techniques to drive performance improvement.
“We use a lot of those tried and true methods of taking employees and physicians and leaders through process improvement in structured ways, so using a model for implementation is important,” he says. “It is not only about saying that you are going to use a best practice from another facility; it is making sure that you use an organized structure and model to do that.”
Address Gaps in Communication
Interventions to improve patient flow do not necessarily need to be sophisticated or expensive. Consider the approach deployed in the ED at Bothwell Regional Health Center (BRHC) in Sedalia, MO.
“When I started at the facility [in December 2015], we quickly identified that there were some communications gaps,” explains Joe Keary, RN, CHEP, the director of emergency services at BRHC. “Most of our communication from the check-in point to the charge nurse or the team lead was via telephone ... so if someone was checking in and the charge nurse was tied up, say helping with a difficult IV stick or whatever the situation was, then they would be the only person who knew that a patient was out there, even though there may have been other staff that were available to get the patient.”
This isn’t the only delay that would arise from the communications issue, but it illustrates the problem that nursing staff would run into when they needed assistance of any kind. To resolve the problem, Keary decided to invest in radios and headsets that the entire nursing staff and the front admitting staff wear now. Under this system, if any nurse needs assistance with a patient, he or she simply can push a button and communicate this need to all other nurses on duty simultaneously.
“The headsets allow for us to then announce to the entire staff that there is a new patient, and anybody who is available can get the patient, put him in a room, and decrease wait time,” Keary notes.
Ease Staff Concerns
The gear is not obtrusive; the nurses all use earpieces that are connected to radio receivers that typically are secured on their belts. Although there is a lot of communication that takes place over the system, it does not overwhelm, Keary observes. However, he acknowledges that it took some time to get the staff thoroughly acquainted with the approach.
“I prefer for my staff to be involved, so I didn’t just say, ‘here are these radios, put them on,’” Keary relates. “We brought the radios in and had a select group use them and play with them, and see what they thought before we decided on a product.”
The first hurdle involved easing staff concerns about who would be able to listen to the radio traffic, and assuring hospital administrators that the approach was consistent with a HIPAA-secure environment. For instance, some people were worried someone across the street with a scanner might be able to hear the radio communications. Staff needed to understand why this is not a problem.
“These are trunked radio systems so they have to be connected together to be able to communicate with each other,” Keary explains. “When the radios are linked together, they are able to communicate, but it prevents anyone else from being able to listen in.”
Once staff felt comfortable with the privacy aspect, they needed a bit of guidance on radio etiquette and the importance of keeping communications short.
“People who had never used radios before originally tried to talk on them like it was a telephone conversation,” Keary observes. “But you want to say just enough to get the point across and then get off the radio. Otherwise, it ties up everybody’s ear for a short while.”
Eliminate Identifiers
In practice, Keary explains that staff members now treat the radio system a lot like EMS radios.
“We don’t give names over the radio; we stick to room numbers,” he says. “The front desk will say they are checking in a chest pain patient or an abdominal patient; they don’t indicate [gender] or a name of any sort.”
Further, while people tend to be resistant to new processes, Keary states that staff adapted to the radio communications quickly.
“Once they tried [the radio system] for a couple of days, they were sold on it, and it didn’t take a lot of oversight,” he says. “Staff members were very much wanting and needing a better communications tool, so once they had one, they jumped all over it.”
Keary acknowledges there are definitely times when nurses need to step away from the radios.
“No one will criticize you when you take the earpiece off while you are having a serious conversation with family members about a disease process or whatever the case may be. In fact, we encourage that,” he says. “And we know the earpieces come off when we are listening to breath sounds because there is no way to have an earpiece and listen to the stethoscope at the same time.”
Nevertheless, Keary says radios are on 90% of the time, and most of the nursing staff are able to hear any messages.
Customize the System
Granted, BRHC operates a smaller-sized, 16-bed ED that averages about 75 patients per day or about 27,000 patients a year, but Keary stresses radio systems can work in larger EDs as well.
“It has to be somewhat custom-tailored,” he says. “I know of a larger, 40-bed ED [that uses the radio system], and administrators there actually had to break it up into a couple of different radio channels because they had too much radio traffic going on, so one-half of the ED was on one channel, and the other half was on the other.”
The ED at BRHC is able to maintain just one radio channel, with about 12 people in radio communication when the ED is at peak volume. Keary credits the radios with helping the department halve its door-to-room time from 18 minutes to nine minutes, and for trimming door-to-ECG times from eight minutes to five minutes.
“We already had processes in place for chest pain ... but sometimes, unfortunately, someone wouldn’t be available to get the patient right away because only one person would get that phone call saying that there is a chest pain patient,” Keary explains. “Now everybody knows there is a chest pain patient, and we get stuff moving a lot quicker.”
In fact, the radio system, which was implemented in the ED in March 2016, has worked out so well that the hospital already has implemented the radios in other departments. Each department uses its own channel so that communications from different departments do not interfere with each other. Keary notes that additional departments are in the process of implementing the radios.
Consider Security Benefit
As far as the ED is concerned, the radios are used primarily by the nurses, although physicians make use of the radios on occasion.
“Where the providers generally sit, do their charting and put in orders — there is a radio there that they will grab and say that they just put in an order or that they need something for a room,” Keary explains. “The physicians have elected not to wear the radios as of yet. I do have a couple of nurse practitioners who wear the headsets and they have found some benefit.”
Although the radios were purchased to improve communications, they also have provided a big benefit in terms of security.
“With the mental health population and the increased number of assaults on healthcare workers, we have used the radios now multiple times to get extra help when a patient becomes violent in a room,” Keary notes. “I have worked in EDs where I had a little cordless phone and I could call for help, but I would be getting one person, whereas with the radio I can have the entire staff at my fingertips.”
SOURCES
- Scott Evans, PharmD, MHA, Senior Vice President, Chief Executive Officer, Sharp Grossmont Hospital, La Mesa, CA. Phone: (619) 740-6000.
- Joe Keary, RN, CHEP, Director of Emergency Services, Bothwell Regional Health Center, Sedalia, MO. Email: [email protected].
Hospitals emphasize the importance of tracking performance, keeping higher-level executives in the loop on key patient flow metrics.
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