End patient wait time in the ED with a promise
After reading this article, you will be able to:
- Describe ED improvement processes Morton Plant Mease Health Care implemented to achieve a 30-minute promise for patients
- Identify steps of the Six Sigma® project to successfully decrease patient discharge time
Patients were waiting too long to be evaluated in the ED at Morton Plant Mease Health Care in Dunedin, FL. It was time—30 minutes of time, to be exact—for a change.
“We promise the public that upon 30 minutes of arrival to the ED, they will be evaluated by either a physician or a physician assistant,” says Kelly Triolo, RN, BSN, MBA/HCM, director of nursing at Morton Plant Mease.
Patient flow in the ED was a large concern at Morton Plant Mease. While reviewing patient surveys, Triolo discovered a reoccurring comment: “My wait was too long.” So she began reading literature and benchmarking against other EDs on best practices to improve overall patient throughput.
During her research, Triolo found the half-hour guarantee policy, which has since decreased ED wait time by 27 minutes at her organization.
“Through the work of a multidisciplinary team, which worked for 17 months on process improvement, we were able to accomplish this 30-minute promise,” says Triolo.
Form a task force
Triolo’s first step in moving toward the 30-minute promise was to have a consultant from ER-One, a company based in Dearborn, MI, conduct an assessment of the ED’s processes and provide feedback regarding necessary changes.
Based on the consultant’s guidance, Triolo formed a task force that involved every discipline in the hospital.
Physicians, staff nurses, case managers, and representatives from food and environmental services were among those who made up the task force.
Triolo challenged each department within the task force to think outside the box and create process improvements related to patient throughput.
By allowing staff members to come up with their own improvement ideas, Triolo gained buy-in and support for the ED changes.
After more than one year of meetings and strategic planning, it was time to roll out the changes. The following ED improvement processes were implemented to achieve the 30-minute promise:
ED bed placement. Hallway beds are now in the ED to get patients out of the waiting room in a timely manner.
Point-of-care testing. Instead of sending a test to the lab, which often results in specimens clotting on the way or even becoming lost, 99% of lab tests are done at the point of care. A new lab in the ED allows blood tests to be analyzed immediately, giving the ED better control of the specimen and a quicker turnaround for results.
Bedside registration. To avoid delays at the front entrance registration desk, staff nurses conduct bedside registration. Patients relay their name, birth date, Social Security number, and medical and insurance information, which is entered into the hospital’s system so physicians can quickly access the information online when assessing the patient.
Staffing. To make the ED friendlier and run more efficiently, a receptionist now greets patients at the front entrance, and a case manager helps verify whether admissions should be inpatient or observation status so patients are transferred to the correct unit.
Bed board operations. One admitting team member operates the bed board system, a device that assigns beds to patients. When bed board operators call a unit to verify open beds before transferring an ED patient, they must assign a bed immediately if one is available.
“If it takes more than 10 minutes to assign a bed, it is considered an error that our task force will look at,” Triolo says.
Bedside triage. The ED’s motto, “Triage is a process, not a place,” created a model shift for the nurses.
A conventional ED has a triage nurse sitting in the waiting room. When patients are admitted, they enter a room with the triage nurse for an assessment. Patients then return to the waiting room until their name is called to see a physician. Now, within 30 minutes of their arrival at Morton Plant Mease, patients are placed in a bed and triaged at the bedside.
The only time patients are not triaged at the bedside is when the ED is at or over capacity and there are not available beds in which to place patients. In this case, patients must be triaged out front and sit in the waiting room until their name is called.
Six Sigma® project. Before the 30-minute promise, 54% of admitted patients were being discharged after 1 p.m. Because the 3 p.m.–11 p.m. shift is very busy, Triolo wanted to decrease that number by getting patients discharged within an hour from the time the physician writes the discharge.
To successfully decrease discharge time, a Six Sigma® black-belt project—a data-driven approach to eliminate defects and create change at the organization—was conducted to help nurses focus on patients who were ready for discharge.
The project also allowed case mangers to get a list of daily observation status patients, who can typically be discharged within 24 hours.
The case manager then follows up with observation status patients to check whether they are waiting to be discharged, Triolo says, “because our likelihood of getting those patients discharged faster is better than inpatients, who are sicker.”
The inpatient units have successfully decreased patient discharge time after 1 p.m. from 54% of patients to 17%.
“If you are not moving the admissions on the inpatient side to be discharged in a timely manner and making way for more patients that are being admitted through the ED, you are just gridlocking the system,” Triolo says.
And to make sure staff nurses are adhering to the new processes on a daily basis, Nancy Hopkins, RN, MSN, CNE, BC, ED manager, roams the unit. “There’s always resistance with changes, so it’s important for me to constantly be out on the unit to help staff conduct the changes and to reinforce that this is the way it’s going to be in order to increase patient satisfaction,” Hopkins says.
See the fruits of the labor
The commitment to making process improvements in the ED was successful.
Patient satisfaction increased from 72% to 94% in regard to overall wait time, and the average time for a patient waiting to be evaluated decreased from 45 minutes to 18 minutes.
“A vision, commitment, leadership, teamwork, consistency, persistence, and a can-do attitude have been keys to this success,” Triolo says.
Adapted from HCPro’s Advisor to the ANCC Magnet Recognition Program®, November 2008, HCPro, Inc.