Process changes cut LOS by 100 minutes
Process changes cut LOS by 100 minutes
'Pivot nurse' speeds treatment of more acute patients
If you're in a brand-new ED and patient flow remains an issue, expansion is clearly out of the question, but that doesn't mean you can't successfully address the problem. In just a few short months, the ED at Forsyth Medical Center in Winston-Salem, NC, has reduced average turnaround time from 135 minutes to 73 minutes.
Patients in the green (lowest-acuity) zone previously were waiting 63 minutes before seeing a doctor, but the wait time has dropped to 26 minutes during similar recent trials. Total length of stay has gone from two hours and 48 minutes to one hour and 48 minutes.
When the new ED opened in 2004, it was double the size of the previous ED and the largest ED in the state, according to Forsyth's marketing department. It was built to handle 110,000 patients a year, but by 2008, it already was seeing more than 101,000.
"We've seen a 6% increase year over year," notes Jason Carter, vice president of operations and emergency services. While Carter notes that the economy might be sending some additional patients to the ED, he says that "we're just seeing an upward trend of sick people." In the past, there was a "cyclical trend" to the patient census, Carter says. "But now, we are not seeing those 'slow times.'"
The department was designed with five color-coded zones for treating different types of patients:
- green for lowest acuity;
- yellow for patients with slightly more serious conditions;
- an orange swing unit;
- red for the most pressing cases;
- blue for patients with behavioral health needs.
Debbie Janes, RN, CSN, CEN, staff development clinician, recalls that despite being designed for efficiency, "we outgrew the new ED from the first day we moved in, to the point where we expanded the bed capacity from 68 beds to 81 beds."
Rick Lee, BSN, RN CEN, NE-BC, the ED manager, says the only option, then, was "to use the space we had more efficiently by changing processes." The first process change made, because it could be implemented quickly, was the creation of the new role of pivot nurse, filled by specially trained RNs and staffed 24/7. "With this increased population of people coming, it puts more pressure on us to rapidly identify people who come through the front door requiring immediate attention," Lee explains. "Having someone at the front door that is trained in advanced cardiac life support, we felt, would have an immediate impact." (Many of the process changes arose from a site visit to Mary Washington Hospital in Fredericksburg, VA.)
These nurses also have taken the trauma nurse core course and an emergency nurse pediatric course, he says. They also have to have been in the department a minimum of one year and meet triage competency criteria.
"It is one of the highest-risk positions in the ED," Lee explains. "They make decisions on who has to come immediately back." The pivot nurse, he adds, is also seen as a "traffic controller." "They're involved with patient flow. They determine which patients can go through to the super-track area and which must go through [the complete] triage process," he adds. They also have ownership within the process, which gives them a sense of urgency to get the patients back to see a doctor as quickly as possible, he says.
After being greeted by the pivot nurse, the noncritical patient goes directly to a room, is immediately seen by a physician's assistant (PA) and a nurse, and receives an assessment. "The PA writes the orders, [tests are] initiated, and then they are either taken immediately to X-ray or care is completed, so this expedites the process," explains Lee. Under the old process, after being seen by the triage nurse, the patients with the least acuity were put "at the bottom of the list" and had to wait until they were called back to a room.
"It's like going to a grocery store that doesn't have a fast lane, having only a couple of items and waiting for several people in front of you who have full carts," Lee notes.
If you're in a brand-new ED and patient flow remains an issue, expansion is clearly out of the question, but that doesn't mean you can't successfully address the problem.Subscribe Now for Access
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