How to cut delays on the front end
March 1, 2000 3 minutes read
How to cut delays on the front end
A benchmarking project that is part of The Clockwork ED Series conducted by the Clinical Initiatives Center in Washington, DC, identified best practices that reduce front-end delays — for example, the time that patients wait before seeing a physician. Here are five best practices implemented by progressive EDs:
1. Profile physicians.
Peer-to-peer comparisons are the best way to change physician behavior, says Kyle Weston, who worked with ED managers participating in the project as a consultant for the Clinical Initiatives Center, a health care organization that performs research for hospitals. "If you hear something from your peers, you take it differently than from someone above," he explains.
The ED at Alton Ochsner Medical Foundation in New Orleans tracks ancillary utilization, consult information, and admission and discharge information, which is used to profile ED physicians, says Joseph Guarisco, MD, FACEP, chairman of the department of emergency medicine. "This information is distributed in a nonblinded fashion to all ED physicians," he says. "Knowledge of each physician’s practice style immediately identifies inefficiencies in his/her practice."
By addressing individual issues about efficiency and productivity, ED managers also uncover issues relating to ancillary usage, time management, admit/discharge decisions, and other behaviors, says Guarisco. "It give incentives to physicians to become involved with the events that occur during each patient’s stay and better understand processes that affect patient care, and to become involved in resolving any issues that delay this process."
As a result of profiling, physicians are aligned with ED goals and objectives, he says. "That is a tremendous plus for a business that runs 24 hours a day."
2. Register patients at the bedside.
All EDs should register patients at the bedside, advises Weston. "There is no reason why any ED should be registering patients differently based on severity. EDs have been traditionally so good with acute patients, so why not non-acute patients? This is a no-brainer."
Laptop computers are most efficient because there is no redundant documentation, but paper bedside registration is another option, notes Weston.
3. Hire consultants chosen by the ED.
The ED group should hire or contract with consultants of their choice for internal medicine and other services, recommends Gabor Kelen, MD, chair of the department of emergency medicine at The Johns Hopkins Hospital and professor at The Johns Hopkins University School of Medicine, both in Baltimore.
"Since this group of consultants works for the ED, the free market should drive competition to some extent," he explains. "Nonresponders and poor performers can be replaced."
4. Implement rapid triage.
Previously, patients were locked into a long tedious process of arrival, waiting, triage, waiting, registration, waiting, and then finally seeing a physician, Guarisco says. "With rapid triage, patients are truly impressed when they are moved from triage to a room."
However, one obstacle is resistance from nurses, who don’t want to do full nursing assessments during triage, Guarisco notes. "This remains a problem since new nurses are coming from traditional training centers that are generally practicing old style emergency medicine. It’s a ongoing battle to convince nursing staff that patient care is improved by doing less triage."
Another spin-off benefit of rapid triage is that patients are available to see the physician immediately, even before registration. "This parallel processing and time-shifting of activities greatly reduces patient length of stay," says Guarisco, noting that the ED has reduced patient length of stay by 27 minutes through rapid triage and bedside registration.
5. Hire a dedicated nurse to improve patient flow.
At Ochsner’s ED, a charge nurse is removed from any clinical activity for each shift to expedite patient throughput. "That nurse’s only responsibility is to manage information and processes and to alert the physician and other personnel, such as radiology supervisors, when things are not going as planned," says Guarisco.
Before this dedicated position, no one pushed the processes to their maximum efficiency, he stresses. "Many times, those delays went unnoticed far too long. Any ED with 15,000 patients or more needs a dedicated nurse manager without clinical responsibilities to ensure efficient and productive patient throughput."
This concept creates a team dedicated to improving the patient’s experience in the ED. Because your ED management team cannot be in the ED 24 hours a day, you need a surrogate management team of charge nurses on each shift whose goals are aligned with department objectives, says Guarisco.
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