Express care improves patient flow in the ED

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Segmenting improves quality, satisfaction

Sun Health Del E. Webb Hospital in Sun City West, AZ, was in trouble. From 2002 to 2007, the ED had seen an 87% growth in volume. Patient satisfaction was low, employee turnover was high, and most patients waited eight hours to be seen.

“Our patients hated us. They told us loud and clear on Press Ganey,” says Noreen Vanca, RN, BSN, MS, administrative director of emergency services at Sun Health.

Like many other ED managers, Vanca knew something had to be done. In 2006, she began implementing the concept of fast-tracking patients with minor and nonacute injuries.

At Rockford (IL) Health System, ED educator Jeff Berg, RN, BSN, TNS, also knew that by treating patients with nonacute injuries (about 25% of his ED volume) differently, he could increase patient satisfaction. A large problem with EDs, he says, is that patients come in with nonacute injuries or even nonemergencies. “These patients could have sore throats, ankle sprains, simple lacerations, or need a prescription refill,” says Berg. “It’s a mix of minor injuries and complaints that used to go to physicians’ offices that, throughout the nation, are ending up in our EDs now.”

Berg says fast-tracking appealed to him because it did not require other departments to be heavily involved in the process change.

“The concept is to get the patients and either their physicians or their providers together as soon as possible. One way to do that is to identify on the front end those patients that are really easy or simple to treat,” says Kirk Jensen, MD, MBA, FACEP, chief medical officer of BestPractices, a provider group of emergency medicine outsourcing services in Fairfax, VA. Jensen also chairs the Institute for Healthcare Improvement’s IMPACT Learning and Innovation Communities, which focus on patient flow in acute care settings and operational and clinical improvement in the ED. He has worked with hundreds of EDs.

“The typical process, in many ways, is to ‘hurry up and wait,’ ” Jensen says. “If you look at what we do, it really is a network of queues. Shorten the network so there are as few steps as possible.”

Successfully creating a fast-track system involves a thorough assessment of the ED, Jensen says. “It’s about fundamentally understanding what’s coming in your front door,” he says. “If your approach to this is just adding more staff, space, and supplies, you can lose money doing this.” Jensen says this process is about rearranging existing resources and matching them appropriately to patient demand.

Implementing change

At Sun Health, where the ED typically sees about 50,000 patients per year, Vanca set out to remove the triage process, which she calls antiquated.

“Triage means limited resources, and if you think about an ED, we are anything but limited in resources,” says Vanca. Processes needed to change. “We had continued to use the same processes when we were [receiving] 19,000 visits [per year] as when we were [receiving] 50,000 visits, and, obviously, we were failing,” she says.

Vanca worked with staff members and outside consultants using Six Sigma Lean methodology to create a streamlined process. Together, they came up with four assumptions about EDs:

  • Not every patient needs a bed
  • Patients come to the ED to see a physician
  • Triaging patients delays the process
  • Full waiting rooms are a liability

With these four assumptions in mind, Vanca and staff members redesigned Sun Health’s ED. First, express care for nonacute patients was implemented. An A side and B side were created. Less-acute patients were tracked through the B side, which remains completely separate from the traditional A-side ED. Patients are assessed by a physician and nurse at the same time, which helps with communication between staff members and lowers the chance of patients being asked the same questions multiple times by different staff members.

After initial assessment, patients are taken to either a specimen area, to start diagnostic tests or IV lines if necessary, or to a procedure room for simple procedures such as setting casts or pelvic exams. They are then taken to a room referred to as “results waiting” to wait for lab tests and discharge. Here, Vanca admits, the patients wait, but, at this point, they are generally more willing to wait.

“They’ve already been seen by the doctor and have been told what to expect,” says Vanca.

Patients are fed and allowed to sit in recliners, watch movies on big-screen televisions, and play with toys. Throughout the entire process, family members are allowed to stay with the patient, which Vanca says helps keep patients content.

Physicians in express care cycle through the same rooms, similar to physicians in private offices, says Vanca.

Berg set up a similar system at Rockford for a seven-day trial in his ED in February. The trial included a dedicated physician to the unit, which was kept separate from the main ED. In an initial trial, physician EDs covered both sections, and express care patients still had to go through the main ED at certain times during their care. Express care wasn’t as efficient because physicians’ time was spent with acute care patients, Berg says, adding that a physician dedicated to the unit helped reduce lengths of stay.

Originally, the express unit had four beds, but Berg took one out to make rooms for consultation, results waiting, and discharge. This way, the unit remained truly separate from the main ED. After removing one bed, the process moved more quickly and efficiently.

After the weeklong trial in February, Rockford’s fast-track process was fully implemented in May.

Seeing results

Staff members at Sun Health were impressed by the process immediately. The night Vanca wanted to go live, she decided it’d be best to begin with an empty ED. To clear out the department, she brought in two extra doctors and four extra nurses. Even with the help, they couldn’t clear the waiting room. Vanca decided to go live anyway. Within one hour of using the new process, and without using the extra staff members, the ED was cleared. Staff members knew then that six extra staff members couldn’t have nearly as much effect as the new express care model.

Using this approach for nonacute patients for two years, Vanca has seen dramatic results. Patients who left without being seen have declined from a high of 14% in April 2005 to a current 0.01%. In the same period, Sun Health’s ED has remained the only one in the area to stay open at all times.

Patient satisfaction at Sun Health now ranks in the 97th percentile (measured by Press Ganey, Inc.), compared to the first quarter of 2006, when the ED had an average of 8% satisfaction.

“These people being discharged from the ED are the ones filling out the [Press Ganey] surveys,” says Berg. “If they have to wait an extended period of time, they’re going to be dissatisfied.”

In his seven-day trial, 54 satisfaction surveys were returned at discharge. The surveys revealed that patients believed length of stay was the most important aspect of their ED visit. The process helped address that, Berg says. By the end of the trial, the average length of stay was less than one hour, and the number of patients who left without being seen was zero.

“In my experience, almost universally, when this is done well, the patients are either very happy or very satisfied with this process,” says Jensen.

Expanding efforts

Costs were reduced when Vanca stopped using outside staffing to supplement an employee vacancy rate of 32% and a turnover rate of 38%. The ED is now 100% staffed, with three potential employees on a waiting list—a side effect of the redesign that pleasantly surprised Vanca.

“The staff became totally engaged,” says Vanca, adding that the entire process was directed by staff nurses, who she says are “owners” of the express care process.

The effectiveness of the new program has bled into other areas. The empty waiting room was made into a staging area for offloading from ambulances, which Vanca says helps comply with the Emergency Medical Treatment and Active Labor Act of 1986. Patients are always taken off ambulances immediately.

With a better process for handling their own department in place, staff nurses at Sun Health’s ED began a program to reduce tensions between the ED and other floors of the hospital. As part of Sun Health’s new “build a bridge” program, ED staff members visit other floors quarterly to inquire about what the ED can do to help them. They gather feedback and share it during ED committee and staff meetings.

Sustaining change

Although Vanca says the simultaneous implementation of a full electronic medical record helped with the ED transformation, she adds that to truly implement an effective express care program, you must push through the change. “You have to know how to manage change,” says Vanca. This includes pushing through when staff members get over the novelty of a new system and begin to covet their old ways.

By week six, Vanca says she was nervous about resistance. However, she says it was about the same time that the staff began to own the process and get used to the new unit.

Owning the process, says Jensen, is an important part in ensuring the success of the program.

“When it’s done well, staff members are part of building out this enhanced way of seeing patients,” he says. “It almost always improves staff satisfaction. Very few healthcare workers are happy with patients waiting. In some ways, the most dangerous place in the hospital is the waiting room, with patients waiting out there that have not been evaluated.”

The idea, Jensen says, is not to force the process onto
staff members. “It’s not a complicated thing to do,” he says. “But it’s not always an easy thing to do, because it involves, at least for some hospitals, a refocusing of their prior priorities and resources.”

Sometimes, staff members who work in the ED to save lives see the nonacute express care patients as an afterthought and are reluctant to change.

However, the process is all about balance, Jensen says. “We want to be fast at fast things and slow at slow things,” he says. “An ankle sprain should be taken care of in a speedy manner, but a patient who presents with acute, severe abdominal pain truly deserves four to eight hours of care.”

Fast-tracking can help ensure these patients get proper care, Jensen says.

Keep patients waiting in the ED updated on delays

Even though ED wait times continue to increase, hospitals can keep their patients satisfied if they keep them posted about delays.

“While patient satisfaction decreases with longer visits, the good news is that EDs can mitigate this dissatisfaction—and actually improve satisfaction in spite of long visit times —by regularly updating patients with information about delays,” according to a new report by Press Ganey, Inc., Emergency Department Pulse Report 2008.

The report looked at more than 1.5 million patients treated at 1,656 EDs nationwide in 2007. It also examined what issues matter most to patients. The top five issues were:

  • How well patients were informed about delays
  • The degree to which staff members cared about a patient
  • How well each patient’s pain was controlled
  • How well the nurses conveyed they were concerned about keeping patients informed about their treatment
  • The amount of time patients waited in the treatment area before being seen by a doctor

“Patients feel personally cared for when providers have human interactions with them,” says Matthew Mulherin, director of corporate communications for Press Ganey. “This includes eye contact, physical contact, and showing interest in their well-being through asking questions and allowing them to ask questions and voice concerns.” Staff members should avoid blaming other departments for delays, he adds.

The report also found that:

Patients spent an average of four hours and five minutes in the ED in 2007, up from four hours in 2006. This continues the upward trend observed from previous years.

A wide variability exists from state to state in the amount of time spent in the ED. Average visit time by state ranges from 2.75 hours to nearly 6.5 hours.

There is notable variation in overall satisfaction based on geographic location. EDs in Milwaukee ranked highest in levels of patient satisfaction nationwide. Rounding out the top 10 in patient satisfaction were the metropolitan area EDs of Columbus, OH; Miami; Detroit; Indianapolis; Pittsburgh; Boston; Kansas City, KS; Chicago; and St. Louis.

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