Teamwork helps cut ED wait times
Six steps let facility guarantee quick service
Just how much can an emergency department (ED) improve if it has the right data? Hackley Hospital in Muskegon County, MI, had complaints about wait times. But until the facility got information about industry norms and looked at programs at other hospitals, it was unable to improve the situation. Once it had the necessary information, the 181-bed community hospital was able to reduce wait times by 75%.
Using data from the San Ramon, CA-based benchmarking company MECON that included information from hundreds of hospitals around the country, the emergency department (ED) brought physicians, nurses, technicians, and admissions staff together to develop a picture of an "ideal" emergency department from the patient’s perspective.
The group focused on how quickly the patient could be brought to a room for care — not how fast he or she could be discharged. Before the project, the average time for a physician to see a patient in the ED was almost an hour.
The hospital formed six multidisciplinary subcommittees, consisting of 35 of the 50 full- and part-time ED staff. The group visited other hospitals but was particularly interested in an ED patient care model used at Harris Methodist Hospital in Arlington, TX.
"We had read articles about how they expedited their patients through the ED," says Gayle Miller, director of performance improvement at the hospital. "They had a seminar where they invited hospital representatives to come down. The major areas we looked at were their bedside registration process, how they triaged patients, their total turnaround time, and how patients were admitted to a unit. They emphasized the importance of working with data and making sure that an outside’ facilitator was selected — someone who didn’t work in ED."
Using a model for a guide to success
While Hackley didn’t completely follow the model at Harris Methodist, Miller says much of it served as a template. One difference was the service guarantee that Hackley implemented. "And we have improved on some of their indicators, such as how fast we get a bed assigned and a patient to the unit."
The performance improvement team created a six-step plan to address the problems in the ED:
1. Admission to the floor.
ED nurses and unit clerks worked with inpatient nurses to revise the bed assignment process. ED staff now transport psychiatric patients, improving bed turnaround. ED physicians also work with hospitalists to improve admission turnaround time by having "new admits" seen on nursing units instead of the ED, when appropriate.
2. Ancillary processes.
A new EKG system was installed, increasing monitoring capabilities from eight to 12 patients, and a Pyramus EKG system was purchased, allowing for old EKG retrieval efficiencies. As a result, EKGs are now done within three minutes of admission for all chest pain patients. Another timesaver is a "clot box," which eliminates the need for pharmacy staff to mix and deliver thrombolytics.
3. Bedside registration.
To save time and improve care, the registration process was moved to the bedside using a laptop computer. Also, the ED patient log was fully automated and insurance pre-authorizations nearly eliminated. A newly created grease board helps staff check patient status. The combined efforts reduced the time to actually receive an admitting bed on a nursing unit from 25 minutes to five minutes.
4. Personnel.
Triage is now handled by nurses, instead of the paramedic/tech, to avoid redundant questioning. Techs now assist nurses and physicians in the patient care area, and uniformed customer service associates provide 24-hour help with duties such as patient-family communication and transport. The hospital implemented staff training and appointed a trauma coordinator and director.
5. Documentation.
Adult and pediatric trauma flowsheets were updated along with the development of new assessment sheets. A staff education program posed the question, "What is wrong with this chart?" Real charting examples showed staff where documentation could be improved.
6. Physical space.
Improvements to the ED space include two new patient rooms and an additional triage area, the purchase of a multiple-use hydraulic chair, and a cosmetic upgrade of waiting and treatment areas. This team also enhanced patient flow by improving the path from triage into patient care areas.
As a result of the program, wait times rarely exceed 30 minutes and average just over 13 minutes. Indeed, the hospital has a service guarantee for patients. Those not seen by a physician within 30 minutes after triage receive a "Hackley Cash" gift certificate worth $5 redeemable at the gift shop, cafeteria, or cafe.
Patient satisfaction surveys were being completed at press time, but the hospital anticipates seeing an improvement there, too.
[For more information, contact:
• Gayle Miller, Director of Community Rela-tions/Performance Improvement, Hackley Hospital Muskegon, MI. Telephone: (213) 728-4642.]
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