Tag: chairs

Emegency Departments That Lag

Time to treatment equals quality for much of emergency medicine.  It’s also the easiest way to decide whether an ED is any good.  Missed diagnoses, errors of judgment, and clinical mistakes can be hard to spot by comparison.

Emergency Departments That Lag

1.  Long Line up at triage –

The most at-risk patients stand in the line-up for triage.  Every day, patients walk in with a deadly process inside of them.  Until they have been seen, they are unsafe.  A line up to be seen is indefensible.

2.  Long triage process –

Triage should be sorting; not a primary nursing assessment.  Patients need a diagnosis and treatment.  In most cases, this means getting patients and physicians together as fast as possible.  A long triage process does not add value for patients.

3.  Long Line up at registration and long registration process –

Registration – getting a chart made – does not add value for patients; it only delays care.  It must be short!

4.  Packed waiting room –

There is no reason for patients to EVER wait in the waiting room.  Please argue in the comment section below if you disagree.

5.  Patients must repeat their story over and over and over.

Providers should quickly check what others have recorded, verify the facts and ask additional questions.  Starting over with every provider drives patients nuts.

6.  No discharge excellence

Patients should leave the ED with copies of lab and radiology reports, written discharge instructions (if necessary), and clear instructions for follow-up and return visits to the ED.

7.  Dismissive attitude

Patients should be welcomed to the ED for ANY complaint.  No complaint is trivial for a patient.  We – healthcare providers, media, government, all of society – seem to think healthcare would be just fine if it weren’t for all the patients.  Besides being unwelcoming non-verbally, there’s a big difference between “Why are you hear today?” and “How can I help you?”

Rules in case you get sick:

Don’t go to your family doc unless you’ve tried something yourself first.

Don’t go to your specialist unless you go to your family doc first.

Don’t go to the ED unless you’ve gone anywhere else first.

Don’t go to the ED unless you are nearly dying.

If you are dying, you shouldn’t go to the ED because we can’t do anything for you…

 

Excuses

But all our beds are full of admitted patients!

Definitely the most popular excuse, admitted patients definitely make it almost impossible to provide emergency care some of the time.  But, even with admitted patients blocking beds, patients should still be brought into the ED and seen on exam tables.  If they can wait on chairs in the waiting room, they can wait on chairs inside after they’ve been assessed.

Thankfully, Ontario has started to hold hospitals accountable for getting admitted patients out of the ED, and up to the wards.

Who owns morale?

Management owns operations; staff owns morale.  Sure, you can crush morale in even the most engaged staff, but blaming management for staff attitudes will mire an ED in under-performance.  Staff control their own morale, and it must be part of performance management.

How does your ED stack up?  As a patient, have you researched your local EDs to see which ones to avoid?  

112 Patient Flow Solutions for Emergency Departments

This list should get us started…  Please add your ideas in the comment section at the end!

  1. Close your waiting room – bring patients straight inside to chairs if no beds open
  2. Use triage to enhance flow: triage = sorting and nothing else
  3. Limit the number of nurses at triage – 1 nurse can SORT 200 patients per day easily
  4. Have patients self triage
  5. Use on-line triage
  6. Use Bedside registration
  7. “Quick Reg” – limited registration; just enough to create a chart
  8. Have patients use self registration
  9. Offer pre-registration on line
  10. Post live wait times on-line to smooth patient volumes
  11. Use patient passports – patient education hand-outs at front door
  12. Educate the community to arrive in ‘slow’ hours (e.g., before 11am Tues – Fri)
  13. Educate community to avoid the surges on Sunday evening/all day Monday
  14. Limit 1 visitor per patient
  15. Encourage patients to bring med lists with them
  16. Encourage community MDs to send in referral notes
  17. Have on-call MDs
  18. Have flexible start and stop times for MDs
  19. Get MDs to take responsibility for flow in real time
  20. Have on call RNs
  21. Shorten nursing documentation (1-2 pages max)
  22. Use combined triage & nursing secondary assessment form
  23. Use physician scribes/navigators
  24. De-zone – move staff to where need is greatest; don’t leave a zone overstaffed
  25. Use advanced directives
  26. Use pre printed orders
  27. Measure and reward MD performance
  28. Measure consultant response times
  29. Insist on in-house consultant coverage for internal medicine, anesthesia, pediatrics…
  30. De-unionize – flow will improve
  31. Have nurses only do nursing tasks (carry out orders, give medications), not clerical work
  32. Track RN break times – insist on accountability
  33. Reward RN extra effort (staying late, skipping breaks, going the extra mile)
  34. Match RN staffing to patient volumes by hour
  35. Match MD staffing to patient volumes by hour
  36. Never allow MDs to go home if waits are long
  37. Staff extra MD and RN shifts on known high volume days (Mondays, holidays)
  38. Encourage MDs/RNs to work in teams and hand over readily
  39. Stagger RN shift changes
  40. Have dedicated ED X-Ray
  41. Have U/S (and tech) in the ED
  42. Use techs for lab draws and ECGs
  43. Stat labs
  44. Prioritize ED lab and DI
  45. Don’t batch
  46. Dedicated porters (RN/tech should porter if porters overwhelmed)
  47. Track DI and lab turn-around times
  48. Get a great EDIS (ED information system)
  49. Create meaningful alerts on EDIS to identify LOS, reassessments, etc
  50. Have a modern EMR linked to the EDIS
  51. Retire outdated EMRs – an old, slow EMR might be worse than none at all
  52. Consider a real time locating system (e.g., RFID)
  53. Consider EMR on tablets for each MD
  54. Computer terminal in each room
  55. Link ED EMRs with community EHRs
  56. Have forms available on-line
  57. Bypass ED for STEMI identified by EMS (straight to PCI)
  58. Eliminate phone calls for CT, etc
  59. Extend CT hours of operation
  60. Encourage the hospital to work on a 24-7 service model (at least a 7 day service model!)
  61. Do not schedule big surgical cases on Monday
  62. Track admits and discharges by time of day and day of week
  63. Eliminate day-day variations of admits/discharges
  64. Perform nurse handover on the ward; not by phone from the ED
  65. Get admitted patients straight up to the ward before a bed becomes available
  66. Use a visual bed management system for inpatient flow admitted patients leave promptly
  67. Use patient flow navigators
  68. Create robust medicine clinic follow-up clinics (next day)
  69. Do not allow consultants to ‘send patients to the ED’ and see them there
  70. Teach residents about quality and efficiency as paramount in their education
  71. Use PO instead of IM, and IM instead of IV treatments if possible
  72. Position EMS off-load in-front of the main nursing station – not hidden away where patients can languish
  73. Form psychiatric patients promptly as needed
  74. Do not perform an internal medicine ‘ward’ work-up in the ED
  75. Order all tests and treatments on the first touch
  76. Plan on disposition from the first encounter
  77. Have Multi-use rooms (eliminate bottle-necks)
  78. Establish procedures to sedate patients in any room
  79. Partner with volunteers – they can help a ton!
  80. Establish CDUs on in-patient wards – do consultations there
  81. Give every MD, RT and Consultants a phone to carry
  82. Do not scale down services over holidays when demand always goes up!
  83. Encourage same day, out-patient cardiac diagnostics and consultation
  84. Establish direct referrals to cardiology (not internal med, NP, cardiology, etc)
  85. Have everything needed for work in every area (don’t make staff walk to the ‘tube system’)
  86. Use pre-printed prescriptions
  87. Have the chief call in 2-3 times per day to monitor flow
  88. Create an internal, real-time ED surge plan
  89. Create a hospital wide surge plan and link it to the ED surge plan
  90. Give admin on call authority to move admitted patients out the ED
  91. Have back on-call to support internal medicine consults
  92. Do not allow surgeons to be on-call to the ED on their OR day
  93. Teach all nurses to apply splints and/or casts
  94. Use ‘just in time’ approach to patient movement – don’t stock-pile patients by loading rooms
  95. Avoid batching
  96. Assign patients to areas; not rooms
  97. Use overhead paging liberally – don’t walk around looking for patients
  98. Improve patient signage
  99. Use patient instruction sheets
  100. Use a re-assessment check-list so MDs aren’t called to reassess prematurely
  101. Build a minor treatment area (aka fast track)
  102. Get rid of as many stretchers as possible (limits holding admitted patients)
  103. Use exam tables where-ever possible
  104. Use some chairs instead of stretchers in the acute area for telemetry patients
  105. Get rid of walls – use curtains to divide most rooms
  106. Eliminate sequential processing
  107. Insist on parallel processing
  108. Look for bottlenecks – theory of constraints
  109. Learn queuing theory and how it applies to your department
  110. Learn and love LEAN
  111. Employ an unlimited capacity mindset – don’t limit flow for lack of ‘rooms’
  112. Adopt a ‘get it done NOW‘ attitude across the organization!

More ideas?  Questions?  Feedback?  Click on leave a reply or # replies below:

ED Stretchers Boarding & Flow

Racing a patient through the emergency department on a stretcher makes exciting TV.

Physician and Nurse Pushing Gurney

But for most EDs, stretchers are the enemy, because stretchers crush patient flow.

Most patients walk into the emerg and walk home – less than 15% get admitted in Canada. There’s no need to force patients to lie on a stretcher unless absolutely necessary.

Patients sit for hours with serious or potentially life-threatening conditions in most waiting rooms.  It’s much safer to get them in and examine them on an exam table inside the ED even if it means they have to sit in chairs during investigation and treatment.

Sure, some patients need stretchers for the duration of their ED visit.  But for most patients, if they can walk, they can sit.  If they can sit, they do not need a stretcher.

Stretchers enable dysfunctional behaviour that makes patients wait.

Stretchers –

1. Attract admitted patients boarding them for days.

2. Act like real estate for ED patients.  Providers assign one ‘lot’ for each patient.

3. Make patients immobile even if they walked into the ED.

4. Allow providers to ‘tuck patients in’, rails up, safe and sound.

Exam tables increase flow by –

1. Removing a spot for admitted patients.  Exam tables are like OR tables:  OR tables are for surgery, not admission.

2. Providing a shared resource for all, not an assignment for one.

3. Getting patients to move, which fosters flow.  Exam tables don’t have wheels.

4. Keeping providers moving with patients.  Exam tables are unsafe without a provider present.  Patients spend minutes on an exam table instead of hours on a stretcher.

Dozens of patients cycle on and off one exam table, whereas one stretcher serves only a few patients per day.  If the average patient spends 6 hours in the ED, each stretcher can serve, at most, up to 4 patients per day and usually far less.

If you haven’t done so already, replace as many stretchers as possible with exam tables.  If exam tables are only found in the minor treatment area, you don’t have enough!

Like any change in historic process, providers realize how attached they are to stretchers when you start asking them to use exam tables instead.  But without building EDs twice the size, we cannot continue insisting that all patients, except the lowest acuity, get seen on stretchers.   Staff support exam tables once they see how much  flow improves; it’s the best way to get patients seen and treated promptly in today’s over-crowded EDs.

Stretchers ruin patient flow, function as a reservoir and promote dysfunctional behaviours. Get rid of them where ever you can!

 

Do admitted patients block your ED stretchers?  Do all your ED patients currently in stretchers actually need to be in one?  Are they blocking flow making other patients wait for care?  Why not replace some stretchers with exam tables?