By Stacey Kusterbeck
As in many EDs nationwide, some patients at Mercy Health-Fairfield (OH) Hospital were waiting over an hour — not to be seen, but just to be checked in. “The most high-risk patient in your department is the one who you don’t know about,” warns Jayne Faber, BSN, RN, senior associate and director of site optimization at US Acute Care Solutions.
Since patients were waiting without anyone even taking vital signs, staff had no way of knowing if those people presented with an emergent condition. During some months, the ED’s left without being seen (LWBS) rate was as high as 8%. Staff worried about patient safety — and their own legal risks. “Patients were waiting a very long time to even to get to triage. The staff understood the inherent risk in that,” Faber says.
Nurses obtained vital signs and implemented protocol orders for some patients waiting to be seen. However, there was not always a technician or medic available to carry out those orders. “There were patients out there who you knew needed something, [but] you were not able to fulfill those needs,” Faber laments.
ED nurses worried patients would decide to walk out without telling anyone, leading to a poor outcome at home or in the community. Leadership met with system leaders to address this ongoing safety concern. The group started out by asking, “What can we do differently or better?”
“We needed to create a system where we can not only see all patients, but complete the care for all of our patients,” Faber explains.
The group decided to create a rapid assessment zone (RAZ) to move people out of the waiting room and discharge them quickly.1 Staff redesigned the triage area to create eight rapid assessment rooms. A triage nurse, an ED technician, and a phlebotomist shifted into this space. Initially, staff worried about losing those team members to the RAZ. Eventually, staff realized “vertical” patients no longer would be going to a bed, and that the new process would expedite everyone’s care.
To learn the benefits of the RAZ, the team analyzed 42,115 ED visits (20,731 before the RAZ was implemented and 21,384 afterward). Patients who LWBS decreased from 5.64% to 2.55%. Median arrival-to-provider time decreased from 28 minutes to 11 minutes. Median length of stay decreased from 205 minutes to 163 minutes.
The initial technician and one of the RAZ nurses give walk-in patients a quick look before placing them in the RAZ. “If the patient is critical, they are directly bedded to the main ED, bypassing RAZ,” Faber explains.
Daily, critically ill patients arrive when there are no available beds in the back. The RAZ answers the question: “How do we make space in the back for them?” Staff use a “vertical care” approach for appropriate patients who do not really need a bed. “More often, there is an open bed in the back for a critically sick patient, because we are keeping patients vertical,” Faber says.
Previously, all patients eventually would move to a bed in the back. By offloading patients who can complete their care without ever needing one of the ED’s 23 beds, it keeps open those beds for patients who really need them. “Treating mid- to low-acuity patients in a vertical space allows us to use the monitored beds for higher acuity patients,” Faber explains.
Difficult situations remain when capacity is strained in the back of the ED because of boarding caused by a lack of available inpatient beds. In the RAZ, providers made some changes to their clinical practice to address this. “It changed the culture; everybody looks at resources differently,” Faber reports.
ED providers no longer assume that every patient will go to a bed eventually. “You start to look at things based on how to get patients to the resources they need, such as a cardiac monitor, IV drip, or even a physician to provide that critical care,” Faber says.
Emergency providers had to become accustomed to “vertical care” orders, such as using intramuscular or oral medications instead of IV or one-time IV antibiotics. Patients with titrating drip medications do need a bed with monitoring; however, stable patients with simple IV fluids can remain vertical.
Clinicians are limiting ordering one-time IV doses of antibiotics, instead opting to order oral doses when the efficacy of the IV and oral dose is the same. “When IV antibiotics are administered, the patient should be supervised to monitor for signs or symptoms of severe allergic reaction,” Faber says.
Back when everybody was assigned a room, starting an IV made sense. “If a patient really needs the IV, obviously they are going to get that care. But it makes you think — does the patient really need all of this? Or, are we ordering it because we assume they are going to get a room?” Faber asks.
The clinical practice changes remain best practice. The US Acute Care Solutions education and legal departments vetted them. “It’s a shift in mindset to use those vertical care orders to try to expedite patient care,” Faber says.
Good communication on the RAZ helps tremendously. Staff explain the new process to patients by stating, “We changed our model of care. You are going to get your labs drawn, and you may not end up being in a room. This is going to expedite your care. You may not be here as long as you used to be.”
Just knowing that labs are processing or that a plan is in development for the patient to undergo an X-ray or CT scan is helpful. “From the patient’s perspective, the wait seems like forever,” Faber says. “But if they know they are moving forward, they will stay.”
REFERENCE
1. Faber J, Coomes J, Reinemann M, Carlson JN. Creating a rapid assessment zone with limited emergency department capacity decreases patients leaving without being seen: A quality improvement initiative. J Emerg Nurs 2022 Nov 11;S0099-1767(22)00277-X. doi: 10.1016/j.jen.2022.10.002. [Online ahead of print].
Using this approach, an ED reported declines in the rate of patients who leave without seeing clinicians, along with shorter median arrival-to-provider and length of stay times.
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