Nurses, physicians work together to move patients
Nurses can improve patient flow by working interdependently with physicians and driving patient care, says Bob Kepshire, RN, MS, CEN, director of clinical operations for the ED at the Medical College of Georgia in Augusta. "There is a lot that nurses can bring to the table to get patients turned around quickly," he notes.
Medical and nursing leadership should operate as a team, Kepshire says. "That attitude has to filter down from the medical director to the rest of staff, that our goal is to help each other out and provide the best care we can. If you don't respect each other, you're going to have a very dysfunctional department."
Collaboration between nurses and physicians is lacking in many EDs, says Joseph Phillips, MD, FACEP, medical director of emergency medicine at Methodist Hospitals in Indianapolis, IN. "It's not uncommon for nurses to spot something, such as a drop in blood pressure, that is significant but not enough so to be dangerous, and they never transmit that information to the physician," he notes. "Likewise, a physician may get lab tests back that the nurse isn't told about."
Defensive attitudes need to change, says Kepshire. "Physicians may take offense, and say, `I'm not going to have a nurse tell me what to do.' Or nurses may say, `That's the doctor's responsibility,'" he explains. "You need to break down turf walls and take a team approach to patient care. That may mean doing tasks you may not normally do, but you'll have happier nurses and physicians, and better patient care."
The ED is an ideal place to take that team approach, Kepshire adds. "What other department teams up nurses and physicians 24 hours a day?" he asks. "The physician should feel comfortable that the nursing staff is capable of doing a good assessment, and there needs to be a mutual understanding and camaraderie on both sides to make this work."
Here are some ways nurses can work with physicians to improve patient flow.
The charge nurse can guide physicians. "The charge nurse really has a global view of what is happening overall, both in the waiting room and in the treatment areas. Whereas, the physician is focusing on certain cases," says Kepshire.
Because of that unique vantage point, charge nurses are in position to help doctors decide which patients they see first. "The charge nurse can let the physician know that this patient is an easy one, and, if you knock this out real quick, there are two tougher ones that will follow that will take up some of your time," notes Kepshire.
Be proactive. "Instead of completing the nursing chart and putting it in a rack somewhere waiting for the physician to see it, seek that doctor out and bring the pertinent information to them," Kepshire says.
Since nurses are responsible for a finite number of patients, they should make sure that information doesn't slip through the cracks, Kepshire says. "If you have a 20-bed ED with four nurses who each have five rooms, the doctor still has 20 patients to worry about," he explains. "Nurses can help get the physician moving in the right direction."
To help move patients through, nurses should keep on top of things. "Look for delays and bring them to the physicians' attention. Question why the lab tests aren't back yet, locate the films, and get the physician to review them," Kepshire suggests. "If the physician is dealing with 20 patients, they can't worry about those details."
Nurses can order tests. "If a physician is tied up in the resuscitation room with a critical case, and more patients are coming in, nurses should be ordering some of these tests," says Kepshire. "Most ED nurses have very keen assessment skills, and they know a patient will need a CBC or urinalysis."
The medical and nursing leadership should develop protocols to allow nurses to order ancillary services. "You need to set up protocols so that everyone is working from the same guidelines," says Kepshire. "Protocols ensure that one nurse doesn't order five tests, while another nurse orders two for the same situation."
Keep on top of lab turnaround times. If a lab result is late, nurses should call the lab and ask why, Kepshire recommends. "Instead of waiting, call the lab and say, `It's been two hours, what is taking so long?'" he says. "If the patient, the family, and the physician are all expecting the results to be back, and there is going to be a delay, keeping all concerned parties informed will reduce frustrations and promote satisfaction."
Prepare for procedures. "The basic preparation of the patient needs to be done every time, so when you walk into the room of patient with back pain, their pants and shoes and socks are off," says Gregory L. Henry, MD, FACEP, chief of the department of emergency medicine at Beyer Memorial Hospital in Ypsilanti, MI, and former president of American College of Emergency Physicians (ACEP). "If I walk in the room, and the child is not in a snowsuit, but in a diaper and gown, that would help get patients through the department."
A clear agreement is necessary. "There needs to be a performance contract between the physician and the support staff, that says, 'This is what we will do, prior to you coming into the room, every time the same way,'" says Henry.
Do as much as possible to prepare for procedures. "If a patient has a laceration, you know they're going to get sutures, so why wait for the doctor to go in there before you get the equipment ready?" says Kepshire. "That doesn't mean you have to open up every sterile set you have, but take in lidocaine, syringes, and the right glove size for that physician."
In some EDs, preparation includes cleaning wounds. "There is no reason why nurses can't prep the wound, numb it, and do irrigation," says Kepshire. "That way, the doctor can come in, suture the wound, and get the patient out the door."
Document what was done for patients during delays. If patients have to wait, record everything that was done for them. "That way, if somebody complains that they were in the ED for four hours, you can go to the record and see that every 20 minutes or so, comfort measures were offered, that ortho was paged for a sprained ankle, and the patient was apprised of delays, and staff were in there six times," says Kepshire.
Often, that kind of documentation falls by the wayside, but it's a good tool to have. "Otherwise, when you look at the chart, you'll have the initial assessment and discharge note, but no record of what happened while the patient was waiting," says Kepshire.
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