EXECUTIVE SUMMARY
To boost performance on a range of metrics, the 55-bed ED at NYU Lutheran Medical Center in Brooklyn, NY, transitioned to a pod system in August 2016. The approach, which is designed to foster team-based care, involves assigning physicians and nurses to designated geographic areas throughout the day, minimizing the movement of physicians as well as the need for phone communication.
- When coupled with other changes, including the introduction of point-of-care testing, the pod initiative has enabled the ED to reduce lengths of stay for all treat-and-release patients to less than three hours for the first time in the history of the department, according to administrators.
- There were multiple challenges involved with the transition to a pod system, including the need to match physician schedules with patient volume, but clinicians note the approach has produced improved physician-nurse communications.
- Administrators credit the creation of a process improvement team with giving frontline staff a voice in planned improvements while also facilitating the change process.
Implementing a new model of care in the ED can be daunting, but when there are good reasons for such a transition — and a well-thought-out plan for implementation — the results can be well worth the effort.
For example, consider the experience of ED leaders and staff at NYU Lutheran Medical Center in Brooklyn, NY. In 2015, a physician working a shift in the large, 55-bed ED could be seeing a patient anywhere in the department, explains Nicholas Gavin, MD, the chief of service in the ED. The approach kept physicians constantly on the move; it also created communications obstacles and resulted in longer lengths of stay (LOS) for patients, he explains.
To fix the problem, Gavin decided to implement a pod system in which physicians and nurses would be assigned to work in teams in specific geographic areas. This transition took place in August 2016.
“Now, when I come on to a shift, I know that my patient is going to be in one of 10 beds, and that the patients who go into those 10 beds will be cared for by a specific team of nurses that I know I am going to work with throughout the day,” Gavin explains. “Previously, I would be working with every nurse in the department on a given shift. Now, I am working with a team of a couple of nurses, so you can imagine how much better the communication is throughout that shift as opposed to being spread across a large ED.”
Further, in just a few months, the move to a pod system has delivered improved efficiency which, in turn, has affected the patient experience positively.
“The most important thing we track is LOS for treat-and-release patients,” Gavin explains. “And through this team initiative, along with point-of-care testing and a couple of other [changes], we have been able to get our LOS for all treat-and-release patients below three hours for the first time in the history of the department.”
What’s more, Gavin notes that patient satisfaction is trending in the right direction.
Although transitioning to a pod system sounds straightforward, there were multiple challenges involved, Gavin acknowledges.
“In order to effectively implement team-based care, you have to match arrivals with the capacity of providers, and that had not been done in the past,” he explains.
Perhaps not surprisingly, massaging the physician schedule so that it matched patient volume did not please everyone.
“We also switched [the physicians] from 12-hour shifts to eight-hour shifts,” observes Gavin, explaining that the change meant that physicians were working more days for fewer hours. “That didn’t win over a couple of people, but most have actually come to like the eight-hour vs. 12-hour shifts.”
The adjustment to a pod system was not as dramatic for the nurses because they were assigned to geographic areas under the old system, and they continue to work 12-hour shifts, observes Kathy Peterson, RN, MSN, CEN, the director of nursing in the ED at NYU Lutheran, but she agrees that the transition has been positive.
“Before [the change to a pod system], the physicians could be two departments over in another area of the ED and not necessarily where their patients were,” she says. “The face-to-face interaction is better ... and the physicians and the nurses like having that interaction together.”
Now, the ED is divided into five pods, three of which are in operation on a 24/7 basis, with the two additional pods open only during peak hours. While managing physician hours presented some initial hurdles, it was always clear that both the physicians and nurses favored the move to a pod approach, Gavin observes.
“We spend a lot less time on the phone with each other because we are in the same proximity and we can talk to each other,” he says.
In fact, Peterson adds that staff members do their best to have both the physician and a nurse on hand to see a patient together so that they can both listen to the complaint at the same time.
“It doesn’t always work that way, but the physician is always in the area and in full view of the patient and the nurse, so it just works better geographically, and it has had a very positive effect,” she says.
Give Pediatrics a Distinct Area
The ED improvements have not stopped with the move to a pod system. Layered onto the pod approach are some additional changes that have made a difference for patient care. For instance, one of the most visible changes involves a revamped approach for caring for pediatric cases.
“In November of 2015, one of the first things I noticed was that our pediatric space was three open bays in the middle of the ED,” Gavin explains. “It was right next to the lower-acuity area in the ED, so you could have an intoxicated, homeless 55-year-old [being treated] 10 feet away from a toddler with the flu.”
From both a patient safety and a family-centered care standpoint, Gavin felt that pediatric care should be delivered in its own separate, secure space, so he decided to redesign what was then the fast-track area into a five-bed pediatric ED, which is now one of the five pods.
“We decided to ... prioritize the care of children and families over the lower-acuity adults, mostly because when you bring your young child to the ED, it can be a pretty traumatic and dramatic experience, and we wanted it to be the best experience possible,” Gavin explains.
Converting the fast-track area to a pediatric ED was not easy. It required equipment and safety assessments, and administrators needed to make sure that the space was equipped with all the appropriate medicines for young patients.
“We needed to do a complete revamp to allow for the safe care of pediatric emergency medicine patients,” Gavin says.
Further, at the time of this change, the pediatric beds were staffed entirely by pediatricians, but in a move to boost quality, Gavin added the services of pediatric emergency medicine specialists to the team.
“We now cover about one-third of our shifts with pediatric emergency medicine specialists and two-thirds with pediatricians,” he explains. “In addition, we have dedicated nurse’s aides for the area, and we recently started a child life specialist program so that at peak hours the pediatric ED is staffed by a physician, nurse, nurse’s aide, and a child life specialist.”
Gavin explains that while child life specialists are more well-known for their work with inpatient populations, they also deliver value in the ED.
“A child life specialist will meet with the patient and their family prior to a procedure and set expectations for what is going to happen,” he says.
Additionally, during procedures, the child life specialist will take steps to distract the young patient from what is going on, perhaps using a computer tablet, a video game, or music therapy.
“We have found that patients and families have a much better experience when the child life specialist is involved,” Gavin explains.
Fine-tune Flow Patterns
Along with the creation of a new, designated area for pediatric emergency patients, administrators expanded the role of the team taking care of lower-acuity or fast-track patients in the main ED.
“Now, we see not only ESI [Emergency Severity Index] 4s and 5s, which are treat-and-release patients, but also ESI 3 patients, which are a little bit higher acuity,” Peterson notes. “We had a process improvement team come together and develop criteria regarding which patients would fit into this category.”
This single adjustment changed the flow right away, Peterson observes.
“It impacts the other areas because not everybody needs to be on a stretcher in the ED,” she says. “It was a positive change. We had some kinks, but we worked through them.”
Involve Frontline Staff
In fact, Peterson views the use of a process improvement team as a key element in the drive to boost performance in the department. She explains that this team includes representatives from all the different disciplines in the ED, and they work together to devise solutions and make implementation plans.
“We like to get staff input, we like to let staff know what is going on, and we like to listen to them because they often have very important things to say because they work on the frontlines,” Peterson explains.
For instance, during the week prior to the planned transition to a pod system, administrators took steps to make sure staff members were fully informed and prepared to make the change, Peterson notes.
“We huddled every day before we started this process,” she says, noting that the huddles occurred on both the day and the evening shifts.
The process improvement team and the commitment to keeping staff informed was a roadmap for success, according to Peterson.
“I think just preparing the staff, getting their input, talking about it ahead of time, and being willing to adapt to changes [were key elements],” she explains.
Further, Peterson notes that administrators timed the switch to a pod system so that it was about one month before the ED transitioned to a new electronic medical record (EMR).
“We changed over to a new EMR system at the end of August, and we started [the pod system] at the beginning of August so that there would not be a whole bunch of big changes at once,” she says. “We tried to space them out a little bit ... and that was helpful.”
The biggest lesson Gavin has learned from the transition to a pod system is the extent to which nurses appreciate a team approach.
“I knew that physicians would be a lot happier because they wouldn’t be running around as much, but our nurses already had geographic assignments, so they knew where they were going to treat patients every day, but switching to team-based care, I didn’t realize how much satisfaction the nurses would have with their experience of working with the physicians,” he says. “Nurses only ever ask for better communication, and this was an enormous step in that direction. I can’t oversell the value of that.”
SOURCES
- Nicholas Gavin, MD, Chief of Service, Department of Emergency Medicine, NYU Lutheran Medical Center, Brooklyn, NY. Email: [email protected].
- Kathy Peterson, RN, MSN, CEN, Director of Nursing, Emergency Department, NYU Lutheran Medical Center, Brooklyn, NY. Phone: (718) 630-7000.
Administrators note an expanded role for clinicians assigned to treat lower-acuity patients and a revamped pediatric area have contributed to improved flow and rising patient satisfaction.
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