ED nurses focus on one set of orders at a time
Paired assessments are done
Nurses in the Scottish Rite ED at Children's Healthcare of Atlanta were frustrated because they were constantly dealing with multiple sets of orders on multiple patients.
A small group of ED nurse and physicians set out to make a change. They wanted to be able to focus on one set of patient's orders at a time, without having to make decisions about which patient to see next until they completed the initial work-up on their current patient.
"We were frustrated by the traditional push process that resulted in more than one patient being assigned to a nurse at one time," explains Ashley Ashkouti, RN, BSN, RN, CPN, the ED's administrative resource nurse.
Three major changes made
Patients were placed in rooms simply because rooms were available, whether there was an ED nurse or physician available to begin care or not. This situation meant a backlog of work for nurses, with patients waiting longer. These changes were made:
1. A team of frontline nurses and physicians developed a "team assessment pull process" that pairs a nurse and physician for the patient's initial assessment.
"A nurse and physician must be matched before a nurse pulls the next patient from the waiting room," says Ashkouti.
2. Once the physician completes the initial exam and verbalizes the plan of care, the ED nurse remains with the patient and completes the initial treatment orders.
These orders might include placing an intravenous line, drawing blood, obtaining urine, performing a strep swab test, or giving medications.
3. The nurse does not take on another patient until the first set of orders are completed on the current patient.
Lauren Timmons, BSN, RN, the ED's assistant nurse manager, says, "Nurses are never overwhelmed any more by multiple patients in multiple rooms with multiple sets of orders."
Patients no longer have to repeat their story to more than one health care provider, and they aren't moved from one location to another for treatment. "Patients are no longer placed in a treatment room, just to wait again for an available nurse or physician," says Marianne Hatfield, BSN, RN, CENP, system director of emergency services.
By combining the nurse and physician initial assessment, the patient and family aren't subjected to repetitive assessments. "The nurse can focus on one set of orders at a time, and does not have to waste time deciding which patient to see next while another patient waits," says Hatfield.
The ED's wait times decreased by 20%, while patient volume increased over the same period of time. Timmons says, "We also found that nurses were better able to meet our targets for door-to-medication in less than 60 minutes for our more critical patients and for patients arriving with severe pain."
Clinical questions
Since the nurse and physician are together for the initial assessment, the nurse can assist with the examination. "The physician verbalizes the plan of care. The nurse and the family are immediately able to ask questions to gain understanding and clarification," says Timmons. "If the nurse thinks that the physician forgot an order, or should have an order, they may ask at this point."
For example, the ED nurse might ask if the physician is planning on giving the patient an antibiotic, or he or she might ask if labs are needed.
The physician doesn't have to try to find the nurse assigned to the patient, and the nurse no longer has to wait for a physician to document the exam before beginning the treatment orders.
"The paired assessment was especially helpful for newer nurses. They are provided with an opportunity to learn about diagnoses and conditions that they might not have previously seen in their practice," says Timmons.
For example, observing the physician completing a complete neurological exam gives the nurse information as to how a neurological deficit might present. "Even experienced nurses found themselves learning new things from the physician during the paired assessment," says Timmons. (See clinical tip, below, on what one ED nurse learned during an assessment.)
Head injury? Watch your patient for this When the "team assessment pull process" was first implemented at the Scottish Rite ED at Children's Healthcare of Atlanta, which pairs a nurse and physician for the patient's initial assessment, a young patient who had fallen and hit his head was being assessed. "The patient had a headache and was sleepy. During our assessment, the patient vomited once and then felt better," says Ashley Ashkouti, RN, BSN, RN, CPN, the ED's administrative resource nurse. "The mom's anxiety level skyrocketed at that point." The physician explained that vomiting once or twice after a head injury is common, but if the vomiting continued, then they would need to seek medical attention right away. Next, the physician explained to the mom what to watch out for changes in behavior or activity, severe headache that wakes the child up at night or interrupts his play so she would know if she needed to bring the child back to the ED. "From that point on, I knew exactly how to better educate families on head injuries and what concerning signs and symptoms to look for in a head injury patient," says Ashkouti. |
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