ED puts registration to bed with laptops
Support from nurses called critical
As part of its initiative for an electronic medical record and focus on rapid service, Sarasota (FL) Memorial Hospital is registering patients at bedside in the emergency department (ED) using laptop computers.
"It’s something new for us," says Alex Freeman, director of patient registration. "We got picked as the guinea pig in ED registration." The ED’s 16 registration staff, he adds, handle between 64,000 and 66,000 patients a year.
The desks where patients used to sit down and register have been removed, Freeman says. Instead, patients are taken directly to the treatment room, where they are registered by employees using a laptop mounted on a rolling table, he explains. "It’s done in real time, and the information goes directly into our computer system."
The patient’s initial encounter is with the triage nurse, either at the ambulance entrance, the ED entrance, or — during its hours of operation — at the adjacent urgent care center, Freeman says. The nurse takes a medical history, assesses the patient’s condition, and puts the patient into the care delivery system based on the needs of other patients awaiting treatment, he adds.
Until that point, registration personnel haven’t seen the patient at all, he says. "Our prompt to be at the bedside is that we’re right by the ambulance entrance and can hear the door open, or the rescue crew hands us a copy of the trip sheet, or the nurse may say that a patient arrived. If it’s chilly, we feel the draft."
In other words, Freeman stresses, there is no clerical delay to the patient receiving care. "We are tracking flow times and are very focused on rapid service, not having the patient delayed in any way. It’s not, Register and wait awhile.’"
The laptops use a radio frequency signal from an antenna in the roof, which allows the information to go directly into the hospital’s computer database as it is entered, he explains. They are dependent on battery power, which has caused "some bumps in the learning curve," he says. "The issue has been whose responsibility it is to recharge the battery, and when does it get recharged. There are two laptops, and one was [inadvertently] set up without a battery indicator, so it was going dead in the middle of a registration."
Each laptop has two batteries, so there is ample power if someone pays attention to the need for periodic recharging, Freeman says. "We had to make a big point of getting people talking about it. Part of the regular conversation has to be, Did you plug it in?’"
Another obstacle came when the laptops began locking up, causing the staff to begin to lose faith in their reliability, he adds. "It wasn’t the equipment, but rather that the BIOS [basic input output system] needed to be updated." Information systems personnel found an updated BIOS on the Internet and took care of that problem.
Employees can use two terminals at a central ED station to update a patient’s file or register new patients when the laptops are both in use, he says. Plans are to get more laptops as the program is expanded into the urgent care center.
Patient response to the bedside registration has been very positive, Freeman says, and the quality of registrations has improved because the interim step of writing information on a clipboard has been eliminated. (For tips on how to improve communication with patients, see story, p. 67.)
The ED nurses deserve much of the credit for the program’s success, he points out. "They’ve been very supportive about inviting the registrar in. If they’re busy with treatment and we’re an afterthought, it’s not going to happen."
Instead, Freeman says, "They have been respectful of the fact that the proper record has to be constructed. Working together this closely has enhanced the relationship between nursing and registration."
Rapid assessment center planned
At present, about 50% of the ED registrations are done on a laptop, but the goal is to expand their use throughout the ED, he says. Future plans also include the establishment of a rapid assessment center (RAC) next to the ED that also would use laptop registration. The idea, Freeman explains, is that Sarasota Memorial’s direct admits — who arrive at different hospital entry points since the dissolution of the traditional admitting department — would be directed through a central point, assessed and registered on their way in. The RAC would be for patients who need an immediate admission but are not appropriate for the ED.
One impetus for the RAC, he adds, is that patient satisfaction surveys show the best way to keep patients happy is to be informed about who they are and the reason for their visit. "If the patient’s first impression is, Nobody knows who I am,’ what are you doing to instill trust in the patient?"
Managed care requirements and the move toward outpatient procedures mean that patients arriving from home or from the physician’s office to be admitted often are extremely ill, Freeman points out. So, unlike the admitting department, the RAC will be a clinical unit, he says.
Registration staff will be at the bedside in the RAC, intercepting patients as they arrive and assessing them before they are taken to a nursing unit, Freeman adds. "The largest proportion are elderly, and they’re getting older and older. Many of them arrive in wheelchairs."
The anticipated future use of the laptops "is to meet the need of the patient to be interviewed in a more appropriate setting than the traditional admitting department," he says. "It’s a quality of care and a customer service issue. It’s meeting the needs of the departments we support, like nursing, more efficiently and with more timely information."
[Editor’s note: Alex Freeman is interested in talking with other access managers who have implemented laptop registration. Telephone: (941) 917-4297.]
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