Cutting-edge discussions of management, policy, and program issues in emergency care
2003; Elsevier BV; Volume: 29; Issue: 6 Linguagem: Inglês
10.1016/j.jen.2003.08.009
ISSN1527-2966
Autores Tópico(s)Healthcare Policy and Management
ResumoAnswer: Initially we tried many other solutions, including an inpatient discharge room and a bed utilization coordinator. Although these solutions improved hospital operations, they did not relieve our ED hallway “holding” problem. Other ideas that either did not work or were never able to be implemented were an ICU “bed ahead” program, canceling elective surgery, and attempts to supplement ED staffing in the face of a nursing shortage. Now when the emergency department can no longer safely care for incoming emergency patients because it is holding admitted inpatients, we initiate a “full-capacity protocol.” The criteria for activation are that (1) the main emergency department is 100% occupied with patients and (2) the ability of the emergency department to care for patients is compromised. The admitted patients who are being held must be appropriate for hallway placement in the inpatient units and all unoccupied acute floor beds must be utilized, taking into account their staff nurse routine competencies. For instance, an 18- to 20-year-old adult could be placed in a pediatric bed and a surgical patient could be placed on medical floors, but a patient requiring neurologic checks would not go to an obstetrical unit. Full-capacity protocol means that the admitted patient waiting for an inpatient bed is moved to the hallway of the floor unit on which the eventual inpatient bed placement will be made. Obvious exclusions include ICU admissions, patients with the diagnosis of active myocardial infarctions, patients hooked up to ventilators or needing frequent suctioning, isolation patients, or any patients receiving more than 4 L of oxygen per minute per nasal cannula (because their oxygen tank runs out of oxygen too frequently). These types of patients make up about 16% of our “held” patients. Telemetry patients are the last patient population to be considered for hallway placement. To qualify, they must have little or no comorbidity and a minimal index of suspicion for a cardiac event. The inpatient unit will watch them with central monitoring. Our protocol calls for each floor unit to get one held patient, as needed. If the ED overcrowding is still not adequately relieved, each unit can receive up to one more patient, but no unit gets more than 2 hallway patients. The inpatient unit decides where to place these “held” patients. Solutions have included a conference room, stretcher alcove, or even across from the nurse's station. Privacy screens are used, and these patients are then given the next available regular inpatient bed on the unit. The only exception is when there are one or more ICU patients waiting in the emergency department. In that case, the next available floor bed goes to an ICU patient transferring out of ICU. This new policy has resulted in minimal unit staff resistance and no union problems. It was presented to the managers as an obvious need to provide adequate, safe patient care. Care is actually enhanced because now patients are going to the staff skilled in managing the type of presenting diagnosis in an area with better nurse:patient ratios than the emergency department can currently provide. It also meets the Joint Commission of Accreditation for Healthcare Organizations proposed standards requiring a plan to decompress an overcrowded emergency department. The New York State Board of Health also supports this plan in the interest of safe patient care. The data regarding what happens to these “hallway” patients are interesting. We found that 28% of patients assigned a hallway bed actually go into a “found” bed by the time the patient arrives on the floor! Of the remainder of the patients, 26% are in the hallway bed less than an hour, and 46% spend an average of 10.3 hours in the hallway. We believe that the concept of putting the problem (eg, “finding” a bed for your unit's patient) in the hands of those who can solve it is responsible for these results. We also found that patients who were admitted to a hallway bed had an average length of stay (LOS) of 5.4 days, whereas patients who are kept in the emergency department have a 6.2-day LOS. This program brought dramatic results. Our patient satisfaction scores rose from the 1st percentile to the 50th percentile of all hospitals, and to the 80th percentile of our system's peer hospitals. —Cheryl A. Barraco, RN, MS, Nurse Manager (E-mail: [email protected]), Karen Kelly-Sproul, RN, MS, Clinical Nurse Specialist (E-mail: [email protected]), and Carolyn Santora, RN, MS, Associate Director for Critical Care Services/Trauma/ED/ICR (E-mail: [email protected]), Emergency Department, Stony Brook University Hospital, Stony Brook, NY Answer 1: Our previous “traditional” arrangement was a large room with 20 to 21 cubicles, one nurses' station, and one unit secretary. Our census and acuity was increasing, and the situation was becoming chaotic. Our 50,000-patient-per-year volume was too high to control through this one channel. In addition, when there were 2 unit secretaries, physicians chose the individual they preferred rather than equally dividing the work between the secretaries. Some “patient choosing” also occurred. Meanwhile, we noticed the success of the staff who seemed more team-oriented during the night shift and in our new adjacent pediatric emergency department, with its own pediatric/emergency board-certified physicians and pediatric staff. Therefore, we set up 2 teams within the department from 8:00 am to 1:00 am, when we have 2 physicians on duty. The second physician who arrives at 8:00 am and the team he or she is on are “bolused” with the next 5 new patients to allow the physician who reported at 6:00 am to finish the patients left from the night shift. Each team has 10 beds, 1 physician, 3 registered nurses (RNs), 1 technician, and 1 unit clerk. The nurse within the team assigns herself to the patient and indicates that assignment on a tracking board. The other team members are responsible for knowing about the patient in general (eg, that the patient in cubicle 2 has chest pain versus knowing all the laboratory results) and helping each other as needed. We have up to 15 “hall patients” at times, and the teams must then flex up to 15 patients with 4 RNs. This new arrangement required adding full-time equivalent (FTE) positions, which were justified by the increased census. A key to the success of this system is the charge nurse, who assigns the patients and EMS runs to the cubicles and monitors the equity of team acuity. The process has become more nurse-controlled, based on resources, rather than physician-controlled or based on personal preference. The charge nurse also helps, as needed, in a crisis and is aware of which patients can be moved out if a room is needed. We modified the charge nurses' hours from an 8-hour shift to 12 hours to improve consistency. We held weekly (now monthly) meetings as we fine-tuned the process. A difficulty we had to work through was the feeling held by some physicians and nurses that they were losing control. We tried adding another team when the third physician arrived. Although it seemed as though this would be a logical step, it did not work. Creating a third physical separation within the department was difficult; staff members were uncomfortable taking critical patients in the separate, but adjacent, location; and there were not enough low-acuity adult patients to justify a separate team. Besides, most of our low-acuity patients were seen in our pediatric emergency department, which will also take some simple adult fast-track patients (eg, patients with lacerations, a simple ankle injury, etc). In addition, nurses did not like the required patient shifting when the staff were rearranged into the additional team. Instead, the third physician now “floats” between the other 2 teams. We have instituted training to help staff communicate, manage conflict, function in the charge role, and be assertive. The staff now have a greater ability to collaborate, and although some people will not change, all must participate. Overall, under the new system, our employee satisfaction ratings have gone up. The new system has minimized any staff member feeling all alone and “sinking” because there is more control over and support for any one nurse's load. The system has provided excellent mentoring opportunities, especially because the charge nurse carefully designs teams that have equity in skill, such as putting an expert nurse with a novice nurse. Unit secretaries now only need to work with a limited number of staff rather than all of the ED staff. Other hospital personnel, such as case managers, remark that it is easier to identify the staff they need for a particular patient. Patient care also has benefited. Our Press Ganey patient satisfaction scores have gone from 25% years ago to 86%. Our average time to see physicians in the main department has gone down to about 28 minutes (9 minutes in the pediatric department), and our average turnaround time in the main emergency department is hours (90 minutes in the pediatric emergency department). —Lisa DiMarco, RN, BSN, MBA, CEN, Administrative Director, Emergency Services (E-mail: [email protected]), and Jan Gillespie, RN, Trauma Program Coordinator (E-mail: [email protected]), Edward Hospital, Naperville, Ill Answer 2: We started practicing zone nursing when we moved into our new emergency department 2 years ago. The new physical design helped support the concept by providing each ED physician and nurse with their own space that can function independent of the other zone. Members within a zone support each other, in a team concept, with the charge nurse and a float nurse available to provide backup during lunch breaks for nurses involved in a 1:1 situation. Each nurse is responsible for tracking his or her caseload of 4 patients, including ensuring that all testing results return in a pre-established time frame and that the ED physician is always busy. Our philosophy is that the way to reduce turnaround time is to always have something for the ED physician to do. The entire process is helped by the improved efficiency of our electronic charting system, which can sort patients by zone. It enabled us to increase our census by 6000 without an increase in staff. We staff zone 1 with an ED physician and secretary for 24 hours a day and zone 2 with an ED physician and secretary for 16 hours a day (9 am−1 am). The triage nurse assigns patients to the rooms, and after midnight, he or she assigns patients to zone 1 only. If staffing is high for the case load between the hours of 3 am−7 am (our lowest average census), we hold a drawing to permit someone to leave early. When we first initiated this system, the unfamiliarity tempted everyone to revert to the old system. However, we tested the zone system for a month, and by then everyone had adjusted to it. We also held 3 team-building sessions to strengthen the bond among the physicians and other team members. Zone nursing works for us. Our average turnaround times are 2.25 hours for discharged patients, 3.5 hours for admitted patients, and 50 minutes for fast-track patients. Our customer satisfaction scores improved from the 59th percentile to the high nineties. —Dotty Kuell, RN, Nurse Manager, Emergency Services, FirstHealth Moore Regional Hospital, Pinehurst, NC, E-mail: [email protected] Answer 1: We found that dividing our centrally located patient “white board” into additional sections improved communication. We have sections for each of the following areas: patient initials, room number, RN who is the primary nurse, a check box for medical screening, a check box for registration, diagnostic tests (eg, laboratory, radiograph), and ready for discharge/final financial verification. Now any staff member can look at the board and see where a particular patient is in the process without having to track down the caregiving nurse for follow-up or to answer a family member's question. Registration personnel can similarly note when it is appropriate for them to approach a patient. The ED charge nurse is primarily responsible for keeping the board up to date and notifying the physician of results, but all staff members (including ancillary departments such as laboratory and radiology) are encouraged to make entries on the board when orders and tests are completed. This communication tool has enhanced our ability to “keep track” of the patient's progress, recognize diagnostic delays, and make timelier dispositions for our patients. —Stephanie Baker, RN, BSN, MBA/HCM, CEN, MICN, Director of Emergency Services, Paradise Valley Hospital, National City, Calif; E-mail: [email protected] Answer 2: Our incoming call volume was becoming difficult to manage for our 84,000-patient yearly census. Many calls to the hospital were inappropriately forwarded to us. For example, one unit secretary would receive a call from a physician answering a page that the other unit secretary had placed, which caused confusion in the emergency department. Our solution was to set up a communication center. We established a dedicated phone line to this communication center, which is the number we ask our outside service providers to use. Calls to this number are answered by an automated system. The message indicates after an initial greeting, “If you are physician returning a page, press 1; if you are EMS, press 2; if you are a pharmacy, press 3….” It also indicates that we do not give any medical advice over the phone. This communication center now handles all incoming outside calls, including pages and transfers (notifying and obtaining approval from the receiving institution and the transportation company, or receiving incoming transfer information/acceptance). The information flow is smoother and our community physicians are happier now that they always connect with someone who is aware of the page. —Maryann Henry, RN, Nursing Administrative Director of Emergency/Trauma Services, Miami Children's Hospital, Miami, Fla; E-mail: [email protected] Answer 3: We instituted several measures that aided our internalcommunication.•A white board to communicate tasks to the ED technician. It was frustrating for everyone when every nurse had to locate and instruct each individual technician. Now, jobs and patient needs are noted on the board, and the technician knows what to do without constant personal direction.•A doorbell in the charting area. Nurses use the counter area in the utility room to do their charting, but the charge nurse used to have to physically walk into the area to call a nurse out. Now, a $20 doorbell chime alerts a nurse that he or she needs to come out for some reason.•Triage sheets are placed on the top of the patient's chart. Sometimes the triage nurse noted something abnormal that the treatment area nurse did not address. The problem was that the triage form was buried underneath everything else. Now that the triage form is placed on top of the chart, the triage assessment findings are more easily seen and staff can follow up on problems. These improvements and others all came about as aresult of our “ED Core Team.”1Kusterbeck S. Boost morale with ‘core team’ of ED nurses.ED Nursing. 2003; 6: 84-86Google Scholar This team comprises volunteer RNs with a minimum of 5 years of continuousexperience in our emergency department and is a forum to resolve problems, make decisions, and set standards. All are asked for their input; anyone meeting this requirement is invited to join the group. As a result of this ED Core Team, morale and results have dramatically risen. Before the core team was formed, there was a 30% vacancy rate; now all positions are filled and several ED nurses from other hospitals are working on a per-diem basis in hopes they will obtain a staff position. —Virginia (Ginny) R. Keusch, RN, Critical Care Services Clinical Manager, Emergency and Cardiopulmonary Departments (E-mail: [email protected]) and Kathleen M. Walter, RN, BSN, Clinical Support Nurse, Emergency and Cardiopulmonary Departments (E-mail: [email protected]), Mecosta County General Hospital, Big Rapids, Mich Answer 1: TriageFirst offers workshops on managing ED work flow. We recommend the following steps:•Develop a report sheet that coincides with the MIVT mnemonic. TNCC and EMS both use the M (mechanism), I (injuries sustained), V (vital signs), T (treatments) mnemonic to cover the essential information for this scenario. Report goes smoother when your form matches the reporting EMS form. Too often superfluous information, such as the primary physician, is being unnecessarily asked of the field providers.•Use “the silent trauma” technique. A lot of dramatic commotion often occurs when a trauma patient arrives. To control this commotion, we recommend the “silent trauma” technique. We keep the patient on the EMS stretcher for the first 60 seconds, and everyone remains quiet. Only the paramedic and lead physician talk, so everyone hears the same report. If the patient is too ill to lie on the stretcher for 1 minute, then he or she probably needs to go to diagnostics or surgery immediately and bypass all ED interventions.The patient is then moved and the physician verbalizes out loud the initial primary and secondary examination while the primary nurse writes it down. This step prevents duplication of effort from nursing needing to immediately perform their initial examination right after the physician.•Have the primary nurse “manage.” The responsible primary nurse should not initially start performing tasks. This nurse needs to orchestrate the “team,” including crowd control and documentation. We have found that these elements, once staff understand and adjust to them, significantly help facilitate the smooth flow and effective care of trauma patients. —Rebecca S. McNair, RN, CEN, Consultant/Educator, TriageFirst, Asheville, NC; E-mail: [email protected];www.triagefirst.com Answer 2: One key learning avenue for improvement has been the videotaping and audiotaping of all trauma cases. The tapes are reviewed within 72 hours only by the trauma program manager and trauma surgical director unless there is a significant learning opportunity that would warrant a group viewing. The focus is not to fault individuals but to look at what the team could do better or what systems or processes could be improved or changed. Patient confidentiality is ensured by our strictly enforced policy. Tapes are placed into a locked box, with only the manager having a key, and they are destroyed after viewing. As a result of viewing these tapes, we have made several changes.•Trauma scissors are now hung from the ceiling. One problem was that nurses did not have scissors readily available to cut off a child's clothes. We provided a pair to every nurse but found that often they were not carrying them. Now we hang trauma scissors from the ceiling of the trauma bay on a retractable clothesline.•Endotracheal tubes are clipped to the wall. We used to keep endotracheal tubes in the automated medication machine (aka Pyxis), but this procedure delayed retrieval of the needed equipment. Now we keep these tubes clipped on the wall at the head of each trauma bed.•Computed tomography (CT) contrast is stored in the emergency department. One treatment delay was waiting for the radiology department to deliver the needed CT contrast to the department. We now store this contrast along with a chart indicating the weight-based dose to administer.•Rapid sequence intubation standardization was initiated. All ED physicians and trauma surgeons agreed to use the same medications and dosing for a rapid intubation procedure, and we created a standardized drug tray. The tray has weight-based cards that let a nurse know immediately the correct dose of each medication to draw up for this particular patient and help speed up advanced preparation.•ED physicians complete an anesthesia rotation. Our ED physicians now do a rotation through anesthesia to keep up their skills in intubating children of various sizes and ages.•We hire the EMS system's EMT-Ps and EMTs. We use EMT-Ps, EMTs, and LPNs in part because there is such a severe RN shortage in Florida. However, I also wanted the individuals in the field to think of and know about our facility for their trauma victims. We find them eager to work for us because we offer them extensive additional educational opportunities (eg, PALS, ACLS, ENPC, and our own 2-day trauma course). By using these measures, we typically meet our goal of having our 500+ per year trauma patients out of the department and into a diagnostic test or surgery within 15 minutes of arrival. —Maryann Henry, RN, Nursing Administrative Director of Emergency/Trauma Services, Miami Children's Hospital, Miami, Fla; E-mail: [email protected] Answer: Our posttriage diagnostic “protocols” were a joint effort between nursing and our medical staff. The medical director approved them, and they are periodically reviewed. They are actually standing orders and we write them as such on the order sheet. That way there is no question by insurers that they were, in fact, ordered by the physicians. The protocols are initiated in triage when there is no treatment space or in the treatment area by an RN when a physician is not available to see a patient immediately. Some examples include the following:Tabled 1Chest pain:17–35 yearsEKG, CXR, PO2 if SOB or Pleuritic (17–35 years) Nonpleuritic, Resolved,EKG, CXR, PO2Brief, 17–35 yearsEKG, PO2Atypical/anginal, >35 yearsEKG, CXR, PO2, CBC, Complete Chemistry, Cardiac Enzymes, Troponin Open table in a new tab Persistent upper abdominal pain (either sex) if >35 years< of age: EKG, complete chemistry, CBC, liver panel, lipase, urine dip. Add KUB flat and upright if vomiting and no BM for 12–24 hours.Tabled 1Low back pain:, atraumatic:Dip UA, wait for MD>55 years either sex:Dip UA, L/S even w/o trauma Open table in a new tab We have found that these protocols are helpful during busy times, and there is a universal understanding and support for nurse-initiated actions. Despite a 6% increase in patient volume, the protocols have been instrumental in decreasing both LOS (from 5 hours to 2.5 hours) and the number of patients who leave without treatment (from 10% to 12% to 5%). —Kevin Trainor, RN, CEN, Nurse Manager, Emergency and Trauma Services, Christus Santa Rosa Hospital, San Antonio, Tex; E-mail: [email protected] Answer 1: When I was a manager at a Baton Rouge emergency department, all of the area hospitals worked to develop a city-wide diversion policy. Requirements included only one hospital being on diversion at a time and limiting the time any facility could be on diversion. However, what we found most successful was developing a network and relationships between the ED managers/directors. When there was the possibility of going on diversion, the ED manager often would first contact the others about their situation. If every emergency department was at near capacity, we would all elect to not go on diversion. Improvement occurred, although it did not solve all the problems. However, our local EMS providers knew there was always a facility available to them. —Trudy Meehan, Principal, Meehan Consultants, LLC, Gonzales, La; E-mail: [email protected]; (225)622-5949 Answer 2: We used to see one hospital after another go on diversion, and the diverted overflow began overwhelming the other facilities. Once everyone was on diversion, EMS would consider everyone open. All the hospitals got together and agreed there would be a no-diversion policy for everyone. In response, our hospital improved triage, cared for patients in the hall, or began placing 2 patients in one major room (which had wiring for 2 cardiac monitors). Interestingly, this approach basically worked, and patients were actually happier. —Ouida Lester, RN, Staff ED Nurse, Western Baptist Hospital, Paducah, Ky; former Night ED Nurse Manager, Baptist Memorial Hospital, Memphis, Tenn; E-mail: [email protected] Answer 3: Cuyahoga County (CECOMS) revised their diversion override policy as a result of multiple hospitals being closed simultaneously and ambulances not being able to find an open hospital. Part of the revision included putting hospitals into regions and defining restrictions, such as critical medical, treat and release only, etc. For a more detailed description of the policies, check http://www.cecoms.cuyahoga.oh.us/. —Nina M. Fielden, MSN, RN, CEN, Clinical Nurse Specialist, Emergency Department, Cleveland Clinic Foundation, Cleveland, Ohio; E-mail: [email protected] Answer 4: I have found that coordination is key. Health Central subscribes to a commercial product for EMS diversion and disaster communication support called EMSystem (http://info.emsystem.com), which serves about 14% of US emergency departments. Maryland has a similar system called County Hospital Alert Tracking System (CHATS). It was developed by the Informational Technology Department of the Maryland Institute for Emergency Medical Services Systems. This is a State of Maryland program that is monitored by the Systems Communications Center and Emergency Medical Resource Center where the hospitals call in and advise them of their alert status (http://www.miemss.org/Home.htm). These systems provide the facilities and those in the field with a real-time data about the status of every emergency department in the area, including resource availability and delayed off-load times. They allow those in the field to make better decisions about transport destination before leaving the scene, and they make facilities aware of what is happening in the community so they can prepare accordingly. —Robert W. Stein, III, BSN, MSHA, RN, CEN, CHE, Clinical Supervisor, Emergency Services, Health Central, Ocoee, Fla; E-mail: [email protected]; also President, LeNurse, Inc, Saint Cloud, Fla; E-mail: [email protected] Answer 5: I have been consulting on this issue for the past decade. I find that some essential elements for a solution include the following:•Hospitals' senior-level executive resolve•A “no blame” root-cause analysis conducted by every hospital•Agreed-upon goals of eventually implementing emergency department and in-house capacity best practices•Standardization of all hospital diversion policies•Standardization of a tough regional policy•A requirement that hospitals consistently going on diversion report their “root-cause analysis” to a regional committee and possibly have a peer review site visit It works! In 2001, Sacramento County, California was averaging 400 diversion hours per hospital. One hospital was on diversion for 23 days straight. We found that diversion was causing diversion; for example, excessive use of diversion and variation of practices drove many of the diversion hours. Today, the culture has changed to anticipate and avoid diversion. As a result, the county's diversion hours were down 50% in 2002 and down 60% in 2003. For more information, check the Web site at www.abarisgroup.com. —Mike Williams, The Abaris Group, Walnut Creek, Calif;E-mail: [email protected]; www.theabaris.com; (888)EMS-0911 Answer 1: Our emergency department (not the entire hospital) offers a weekend “perk” that evolved from our staffing committee. Ordinarily an RN is expected to work every other weekend. However, a nurse who has been here ≥10 years works only 3 out of 8 weekends, and those with ≥20 years work 2 out of 8 weekends. This practice is optional; a few nurses choose to work more weekends because of other issues, such as babysitting. Most nurses are very pleased to be able to have the extra weekends off. The hospital recruitment and retention committee is looking at a no-holidays option after 30 years. Questions about the cost of these changes are often raised. However, it is cheaper to pay a per-diem or newer staff nurse the time-and-a-half for these shifts rather than an RN who has 20 years' longevity. Their hourly rate at time-and-a-half is considerably more. —Virginia (Ginnie) Hebda, RN, BSN, CEN, ED Nurse Manager, Thompson Health, Canandaigua, NY; E-mail: [email protected] Answer 2: Staff ordinarily work a schedule that includes every other weekend. However, about a year ago the Shared Governance Committee, with our Clinical Supervisor Sheila Hunt, RN, MN, looked at how staff chose their shifts when nurses left or changed their schedules. As a result, based on the nurses' seniority in our department, we offer a limited number of “Baylor option” schedules (eg, two 12-hour weekend shifts). Designated times are any shifts from 7:00 pm Friday to 7:00 am Monday, and the nurse is paid time-and-one-half. The caveat is that a “Baylor” nurse can only request off 4 weekend shifts per year. As a result of this Baylor weekend program, some nurses (also based on seniority in the department) have a weekday schedule with no weekends. Some senior nurses did not chose either option; they wanted weekend pay differential or weekdays off for other scheduled activities. As a side benefit, these options make it easier to cover the department on the weekends and to have a nice mix of experienced and less experienced nurses on weekends. —Beverly (Bif) Fink, RN, BSN, MSN, CEN, Clinical Director, Emergency Services, Tacoma General Hospital, Tacoma, Wash; E-mail: [email protected] Answer 1: At ED registration, we ask the patient if he or she wants information released. If they initial the section for “no,” a sticker system is utilized to alert staff that no information is released. If callers inquire about this patient, our scripted reply is “We have no information on anyone with that name.” If they initial the section for “yes,” we ordinarily release information only if the caller inquires about the patient by name. We indicate that
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