Administrative support helps keep your LOS low
There are times when EDs can achieve dramatic improvements in average length of stay (ALOS) or reductions in their left without being seen (LWBS) percentages in a relatively short period of time by instituting significant new process improvements, such as bedside registration or new triage protocols. That’s not, however, the only way to achieve excellence in these areas — and it may not even be the best, according to some sources interviewed by ED Management.
At Wilson Memorial Hospital in Sidney, OH, for example, ALOS is 78 minutes and LWBS is one in 300 patients, but that has been par for the course at Wilson Memorial for quite some time. "For a number of years, we’ve had very low treat and release times," says Linda Maurer, RN, director of critical care services. She says such ongoing excellence is due to a combination of factors at Wilson. "Nursing is a piece of it, but most of [the credit] goes to administrative support," she says.
Fred Haussman, MD, the ED’s medical director, agrees. "I’ve been here 20 years, and would not still be here if they were not supportive," he says. "The most important thing is they understand the importance of the ED as the front door’ to the hospital." In fact, he says, that support "is stronger now than I can remember."
The ED keeps very close tabs on their patient flow and shares it with administration, adds Maurer. "We are very data-driven; we carefully track our hours per patient," she explains. "When the load goes up, we take those numbers to them, and they support our adding staff."
The ED is approaching 30,000 visits per year, according to Haussman. "We have seven full-time ED docs that staff the ED and are part of Premier Healthcare Services, which is contracted to provide emergency services," he says. There are 38 full-time equivalents (FTEs) in the ED, including 52 RNs, patient care technicians, and secretaries.
Haussman and Maurer agree it takes much more than a supportive administration to achieve and maintain such numbers. Premier also is partially responsible, notes Haussman. They provide the proper physician staffing in the ED at the right time, he says.
"We do not run three-fourths patient-per-hour volume like some EDs get pushed into," Haussman explains. "Premier will provide us with the proper number of physicians so they aren’t all running around and not providing good care."
Also critical is the staff’s willingness to take on additional roles within the department, he says. "There’s a good deal of cross-training in our staff," Haussman says. "They go to inservices and have to pass a proficiency test to be allowed to perform different tasks."
At Wilson Memorial, they do all their own phlebotomy within the ED, Maurer says. "We draw the blood ourselves, print the label, and take it to the lab," she reports. They do all of their own 12-lead EKGs, so they don’t have to wait for a physician. "Anything we can come up with and do ourselves, we go with."
All the ED patients have priority over outpatients, says Maurer. "All the labs automatically run STAT when tests come from the ED," she says.
The cross-training saves a great deal of time, she says. "We couldn’t get patients in and out if they had to wait for an hour and a half for urine and X-ray," Maurer explains.
Support from other departments is critical, Haussman says. "If we did not all work efficiently together, we would not have success."
So much for fast’ track
One of the more significant single timesavers for the ED, ironically, was the discontinuation of a fast-track triage service, says Haussman.
"We used to have it to try and separate out minor cases in the evenings, and triage the patients into a separate area next to the ED," he recalls. It sounded wonderful, but they never could get triaging to work quite right, Haussman says. "When they were busy, we weren’t, and vice versa," he says. "We saw a real success when we moved into our new ED in 1997 [and discontinued fast-track.]"
Haussman says he’s been able to bring both the physician from the fast track and the one from the traditional ED into the ED in the evenings now, and all patients are seen through the ED.
The goal is not to increase LOS for ankle sprains, Maurer emphasizes. The LWBS was higher when they had fast-track, Haussman says. "A lot of people would come in at a certain time, and we’d get a huge bolus of patients who could not all be accommodated, so people would leave and come back the next day," he says.
Today, Wilson Memorial’s LWBS averages fewer than five patients a month, says Maurer.
Sources
For more information on reducing average length of stay, contact:
- Fred Haussman, MD, Emergency Department Medical Director; Linda Maurer, RN, Director of Critical Care Services, Wilson Memorial Hospital, 915 W. Michigan St., Sidney, OH 45365. Phone: (937) 498-2311.
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