By Rebecca Hendren, for HealthLeaders Media, July 12, 2011
The introduction of a new role in the emergency department at St. John's Hospital in Springfield, MO, has transformed throughput and improved patient experience.
The ED was experiencing about 220-240 visits each day and wait times were growing so long that patients were leaving without being seen. To improve patient satisfaction, staff wanted to improve the throughput process.
Triage was a big stumbling block for the ED. Nurses greeted and triaged patients in the waiting area, and dealt with radio communication with incoming ambulances and EMS personnel. The nurses often asked patients to wait while they dealt with a radio call. The ED receives 60-90 ambulances every 24 hours, so it was a major distraction for nurses and patients.
Enter "the wizard." Officially known as an ED flow facilitator, the wizard is assigned to radio calls, which allows triage nurses out front to concentrate on the patients in front of them.
The wizard, a registered nurse with exemplary triage experience, triages patients arriving by ambulance and ensures that everything is ready, and serves as a bed czar for the ED whose prime task is throughput.
"The purpose of the flow facilitator is to have one person who would be air traffic controller," says Rachel Corle, RN, one of two wizards in the ED. Corle says the role involves keeping an eye on everything and proactively planning how to move patients through the ED. The wizard watches the waiting room, knows what's going on in the back, and is responsible for assigning patients to beds. The role involves constant communication with the triage staff and all care providers.
The bed wizard:
- Gets discharges out of ED rooms
- Gets rooms cleaned and ready for the next arrival
- Gets next incoming patients out of triage and into their room
- Keeps tracking board updated and monitors delays
- Handles patient room assignments
- Is the contact for all bed control issues
- Serves as a point person for RN, tech, and physician patient status updates
- Directs and assists staff with prioritization
- Alerts RNs of pending orders
- Performs results follow through
- Handles anything with a "time stamp"
"This is one of the most important jobs in this ER," says Lane Burroughs, ER nurse manager. "[The wizard] has to be someone with very good organization skills and assessment skills."
"It's just phenomenal what it's done for patient throughput" says Corle. "We have decreased the amount who leave without being seen. We are getting them back quicker. Economically, it's been an improvement in getting more customers in to be seen."
With the wizard, the ED also implemented a direct bed system where patients are brought back to open beds immediately after triage, rather than spending time in the waiting area before being called back. The wizard tracks open beds, makes sure just-vacated beds are cleaned quickly for the next patient, and pulls patients in from the waiting area as soon as a bed is ready.
It allows the ED to assess patients once and get them in a bed. Before the wizard, each patient was assessed by the primary nurse, with a secondary assessment when they reached their beds, which took about 20-30 minutes.
"Why are we doing that when we could direct bed them?" says Lane. "The first person they see is a registered nurse. The triage nurse talks to them and does an assessment. If we have a bed open, they now go to a bed, whereas before they did not."
Other changes include sending patients immediately for x-ray and having a phlebotomist at triage who can start lab work. All these initiatives have dramatically reduced patient wait times, which increase satisfaction.
"In the departments where flow facilitators have been implemented, the most impressive improvements have been in the walk out rate," says Deb Delaney, RN, senior consultant with BlueJay consulting. "No hospital wants patients who have come for care to walk out because they are frustrated with the wait. In one ED the walk out rate dropped from over 7% before the implementation to 2.7% after the flow facilitator was appointed. Additionally, the overall length of stay for patients improved by over 40 minutes per patient and the customer service scores went from 51% to 83%."
Delaney explains that the wizard focuses only on the ED, which is different to a traditional bed czar role. Since the average admission rate for ED patients is 20%, the hospital bed czar can assist with moving those patients. The ED flow facilitator, however, concentrates on the other 80% of patients who are treated and discharged.
"We can see what a positive outcome it's had for patient satisfaction," says Corle. "It works and is something everyone in the whole department is proud of."