By Dorothy Brooks
While some EDs have yet to see the kind of patient volumes they were accustomed to before the pandemic, that is not the case everywhere.
By last summer, average patient volumes in the ED at Hackensack Meridian Health’s Southern Ocean Medical Center in Manahawkin, NJ, already were pushing prepandemic numbers, causing a strain on staff and producing longer wait times for patients.
“After COVID was calming down a little bit, our ED volumes exploded, so we were having a lot of patients who were leaving without being seen,” explains Kelly Murphy, RN, BSN, BC, the ED nurse manager in the ED at Southern Ocean. “We are a community hospital, and I didn’t want that for our community.”
Consequently, Murphy began researching an approach developed and implemented successfully at Hackensack University Medical Center, a sister hospital within the Hackensack Meridian Health System. Called “Pull to Infinity,” the approach is designed to kick patient flow up a notch when the ED is full and patients continue to present for care.
Key to the tactic is what hospital administrators refer to as the ED’s triage hallway, a space outfitted with 13 recliners, curtain dividers, and dedicated staff.
“We no longer do full triage and then send patients back to the waiting area,” explains Michele Morrison, MPH, BSHA, RN, president and chief hospital executive at Southern Ocean Medical Center. “We bring them to the triage rooms for a very quick vital signs and chief complaint [check], and then bring them right into our triage hallway, where we start treatment.”
Once a patient is stationed in the triage hallway, a nurse will complete the triage process and determine the appropriate Emergency Severity Index. “Then, the nurse will start interventions based on what the patient is there for,” says Murphy, noting any needed labs or imaging tests will be ordered right away.
There also are advanced nursing initiatives in place that enable nursing staff to provide some treatments even before the provider has seen the patient. For example, this could involve placing a splint, performing an ECG, or providing needed first aid.
When the back of the department is full, the physician will begin the medical screening exam while the patient is in the triage hallway. “Further, for some patients, treatment is completed in this space, and they are discharged directly from [the triage hallway],” Murphy says.
Since Pull to Infinity was implemented in June 2022, the results have been impressive. The average time it takes to see a provider in the ED has dropped from 22 minutes to seven minutes. This has occurred despite continually expanding volumes. Before the pandemic, the annual volume in the ED was roughly 38,000 patients. Now, that number is up to more than 42,000.
Other operational metrics have improved as well. For example, administrators note the average patient arrival-to-discharge time has improved to 175 minutes, down seven minutes from before the Pull to Infinity approach was implemented. Also, importantly, the leave-without-being-seen rate declined from 3.5% last year to 1.6% in the first four months of 2023.
In addition to accelerating care, Morrison believes the new approach bolsters patient safety. “No one was really keeping a close eye on those people. We were following up on patients over a period of time to re-check their vital signs and status, but when you are in and out of the triage room, you don’t have eyes on every patient all of the time,” she says. “This new mechanism gives the team the ability to keep an eye on every patient, constantly re-evaluating what is happening with them.”
The approach has eased some of the stress on staff who grow concerned when the volume of waiting patients grows hour by hour. “That comes to feel overwhelming,” Morrison observes. “The buy-in from the team has really been tremendous. At the end of the day, it is a great satisfier.”
Morrison says Pull to Infinity has boosted patient satisfaction, too, because they no longer have to go back to the waiting room until a provider is ready to see them. “Staff have scripting they use when they bring patients to the triage hallway and explain to them what the process is,” she says. “Our patient experience scores have soared from June of [2022] when we implemented the process. They have only gotten better.”
Murphy believes involving staff early has been key to Infinity’s success. “[Staff] knew we had to work on the front-end process of the ED. Really, it was a collaborative team effort, with everyone suggesting some ideas on what to do,” she shares. “When we finally did implement Pull to Infinity, my assistant and I worked the [triage hallway] area to kind of model what it should look like for the first few weeks. Then, we just continued to communicate with the team about what was working and what was not.”
Infinity has not required adding any staff, but there has been some rearranging. For instance, Murphy notes positioning the triage nurses in the triage hallway rather than in the triage rooms is more efficient.
“Also, some of the physicians now use computers on wheels to see patients in the department, and the flow has been just incredible,” she reports.
It is important to communicate to staff the “why” behind plans like these. “I think once teams understand that, there is more of a buy-in, and then they participate in the change,” Murphy observes.
Morrison agrees, but she also sees improvement as a continuing process. “We haven’t reached all of our goals, but we are constantly reviewing the process,” she explains.
For example, hospital administrators want to shorten the average patient length of stay in the ED to 130 minutes. That might require some interdisciplinary work with other departments that work closely with the ED.
To that end, Murphy notes that over the past year, the ED has implemented the I-PASS approach within the electronic medical record to streamline safe handoffs for patients who are admitted from the ED. Learn about I-PASS method at: www.ipassinstitute.com.
Since Pull to Infinity was implemented in June 2022, the average time it takes to see a provider in the ED has dropped from 22 minutes to seven minutes. This, despite continually expanding volumes. The average patient arrival-to-discharge time has improved to 175 minutes, down seven minutes. Also, the leave-without-being-seen rate declined from 3.5% last year to 1.6% in the first four months of 2023.
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