Virtual beds’ lower flow times, boost satisfaction
Can staff watch patients closely enough?
Some ED managers call the system "virtual beds;" others prefer the terms "outside waiting room," or "waiting room by appointment." Whatever you choose to call it, it’s a "no wasted real estate" approach to ED management that can help you decrease door-to-doc times and increase patient satisfaction.
In such a system, the ED takes patients who potentially can be discharged quickly, puts them in a room, examines them, then discharges them or puts them back in a waiting room after minor ancillary testing has been done, explains Diana S. Contino, RN, MBA, a consultant for California Emergency Physicians /MedAmerica (CEP/MedAmerica), a Laguna Hills, CA-based emergency physician management company. The system also allows for nontraditional patterns of ED staff utilization.
Lab or radiology testing is frequently ordered up front, and patients are taken to those departments or testing is done in another area of the ED, she says. "California Emergency Physicians utilize these processes effectively at many of their sites," she says. Contino estimates the system is being used at one-third to one-half of the CEP facilities, some of which see upward of 75,000 patients a year. At those sites, the process is referred to as rapid medical evaluation (RME).
There is a big difference between an RME system and a fast-track service, Contino says, and that difference also is RME’s greatest advantage. "A fast-track system is for low acuity patients where everyone still goes through the same process — sign-in, MD evaluation, registration — and it all happen sequentially," she explains. "The whole concept with RME is that in some cases, you can eliminate some of the steps — like nursing assessment — and you also do them at the same time." So, for example, while the doctor is seeing the patient, the nurse is also in the room, and the patient can be registered there as well. "That’s a big advantage," Contino asserts.
To minimize the confusion about patient location, the staff and physicians work as a team to identify specific patient flow and processes, she says. "The entire patient flow is enhanced with patient tracking software, but as with any tool, it only works as well as the staff fully utilize it."
Patient tracking software is not necessary for RME, however. "There are several CEP sites that still use the old traditional white board," Contino notes, "But again, it’s only as good as your staff; for example, they have to make sure the board is constantly updated."
There is a direct link, she says, between patient satisfaction and door-to-doc time. The RME process has allowed physicians to decrease the CEP average door-to-doc time from 48 minutes to between 35 and 40 minutes, and the patient satisfaction scores conversely increased from 4.12 to 4.31 on a 5-point scale, Contino reports. "Also, moving these patients out of the ED yields expanded capacity," she says.
Emergency medicine experts say this type of system is not always popular with ED nurses, because they take issue with the fact that these patients still have pending tests and needs and they want to keep an eye on them. "One way around this problem — and we focus on this within CEP — is identification of nonurgent patients," says Contino. "Some ED patients, for example, do not need to see a nurse." For example, with a nondeformed weight-bearing ankle injury in an adult, they could be seen in their doctor’s office, if they were able to get an appointment, where they might see a physician’s assistant (PA), nurse practitioner (NP), or a physician and a medical assistant, but not a registered nurse.
Some of the nursing directors at CEP sites have changed their nursing policies and procedures and forms to allow the NP, PA, or physician in the ED to see, treat, and discharge the patients who do not require nursing care (medications, nursing interventions etc.), says Contino. This change has allowed the RNs to focus on the patients who truly need nursing assessments, ongoing monitoring, and interventions. "In many cases, this has improved nursing satisfaction because they are no longer bogged down with nonurgent’ patients," Contino asserts.
While CEP has been pleased with this approach, William Beaumont Hospital in Royal Oak, MI, has had an entirely different experience.
"We tried it about a year and a half ago, but abandoned it," says Antonio Bonfiglio, MD, FACEP, chief of emergency medicine.
This had nothing to do with nurses’ complaints, he says. "We simply have too high a volume to be screening patients effectively at the front," he says. "We see 30 patients in an hour, and trying to weed through high- and low-acuity patients at the front was very difficult for us."
Beaumont has had an observation unit in its ED for nearly 10 years, and that unit has proven quite successful, says Bonfiglio. This is reserved for patients with maladies expected to be resolved within 18-24 hours. "Only about 5%-7% of those patients get admitted," he says.
The Beaumont ED has also developed an express admission process, in collaboration with the internal medicine department. "Low-acuity patients go right to the floor, where work is completed," Bonfiglio says. "It’s a quicker hand-off."
As for why Beaumont’s "outside waiting room" did not work, Bonfiglio says the bottom line is that "we got to the volume point that the process broke down for us."
Contino says that with such a system, an increase in volume is almost inevitable. "When you try the system, because you are more efficient and see more patients, the volume goes up," she explains. "If you do not then modify your processes and staffing, you can’t adjust to the higher volume."
Sources
For more information on virtual bed systems in the ED, contact:
- Antonio Bonfiglio, MD, FACEP, Chief of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI. Phone: (248) 898-1968.
- Diana S. Contino, RN, MBA, California Emergency Physicians/MedAmerica, Laguna Hills, CA. Phone: (949) 461-5200. E-mail: [email protected].
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