ED flow facilitators make throughput center stage
Position frees nurses to oversee core measures
On any given day, the ED at Mercy Hospital in Springfield, MO, has two zone captains acting as mini-charge nurses, for the east and west sides of the department. There is also an up-front triage nurse who is the first person most patients see when they walk in the door, and a lobby nurse who regularly rounds through the waiting room, taking vital signs and monitoring patients who have yet to see a provider.
These types of personnel are common to many busy EDs, but in the fall of 2010, ED staff decided the department needed someone who could focus all of his or her energy on throughput. Yearly volume at the time was 93,000, but it was rising rapidly along with the left-without-being-seen (LWBS) rate, which was hovering in 8% territory at the time.
Administrators decided to put the problem in the hands of front-line staff to resolve, believing they had the best understanding of the issues involved. Consequently, the staff created a new position with the formal title of "ED flow facilitator," although they often use different terminology, referring to person filling this position as the "bed wizard."
Look for good multi-taskers
"The role of the bed wizard or ED flow facilitator is to monitor the in-and-out throughput on each zone, and she also takes charge of ambulance calls," explains Ted Shockley, RN, CNRN, administrative director of the Emergency Trauma Center at Mercy Hospital Springfield. "We have anywhere from 60 to 80 ambulances that arrive between 11 a.m. and 11 p.m. every day."
The ambulances were getting to be too much to handle at the triage desk, so it made sense to couple this task with the overall responsibility of managing flow, adds Shockley. "The flow facilitator assigns patients, so her main job is to watch the flow of patients coming in through the waiting room to each zone, and to try to distribute the flow as equally as possible."
While the zone captains coordinate with the flow facilitator, they focus on managing their respective areas, facilitating tests, taking in new patients, and getting patients discharged or admitted. "On rare occasions, the flow facilitator will take in a new patient," says Shockley, but he stresses that the ED tries to avoid that because it takes the focus off of throughput. "As soon as she gets bogged down with patients, the whole team kind of slows down."
Meanwhile, the charge nurse is able to oversee the entire department, focusing on core measures, quality assurance, and staffing. "They look several shifts down the line and make sure we are not short somewhere because doing a schedule for 200 people is tough," says Shockley. "They concentrate on functional, departmental issues and the flow facilitator does throughput."
The most challenging aspect of the job is finding space for higher acuity patients when the ED or hospital is overwhelmed, according to Gayla Reynolds, RN, one of the ED's flow facilitators. This is the boarding issue that affects many EDs, and is associated with poor ED flow. "A typical bottleneck is when people have been seen and admitted, but the hospital has no beds or is waiting on discharges," says Reynolds. To resolve the problem, flow facilitators usually call a hospital supervisor, who can then take steps to speed up the discharge process, she says.
What type of person makes a good flow facilitator? "They have to have a deep understanding of throughput, and generally we use nurses who have been here a while," explains Shockley. Some of the flow facilitators would make good supervisors, but many prefer to stay involved with nursing care, he adds. "They may work as a flow facilitator two days a week, and then the other days of the week they will be a general nurse. They like that mix."
Reynolds adds that flow facilitators need to be able to multi-task, and to be "willing to get their hands dirty," if need be, cleaning beds, or whatever is necessary to keep the patients moving. "It can be highly stressful, so flow-facilitators must be able to remain professional and to keep things in perspective," adds Reynolds.
For solutions, listen to staff
The home-grown position has clearly delivered. Within months of implementing the flow facilitator position, the LWBS rate declined to the 3% to 5% range, and there were also slight declines in length-of-stay and door-to-bed placement times, says Shockley, but he notes that managing volume remains a challenge as the daily census continues to climb. "We treated 95,740 patients last year, and we are now on track to see 97,000 or maybe even 100,000 this year," he says. "We had one day not long ago when we had 31 walk-in patients in one hour, and I only have 45 rooms."
Other busy EDs could definitely benefit from the use of patient flow facilitators, says Shockley, but he emphasizes that each ED needs to fashion a solution that fits its own circumstances, and it is critical to stay on top of patient use patterns. "You can't do the same staffing pattern when your patient patterns change," he says. "We look at [our numbers] at least quarterly, if not more," he says.
Shockley also advises ED administrators to look to their front-line staff for solutions when trying to improve a process. "Sitting back in this office from the 30,000 mile mark, I don't know all the details," he says. "The staff came up with the idea for a patient flow facilitator, and it is working quite well."
Sources
- Gayla Reynolds, RN, ED Flow Facilitator, Emergency Trauma Center, Mercy Hospital, Springfield, MO. Phone: 417-820-2115.
- Ted Shockley, RN, CNRN, Administrative Director, Emergency Trauma Center, Mercy Hospital, Springfield, MO. Phone: 417-820-2000.
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