Tag: Patient Flow

See What We’re Trying Next to Improve ED Patient Satisfaction, Quality and Flow

So far, we’ve posted what works.  In two days, we will try something that (almost) never works.

MP900309330

 

Does repeated failure mean something is impossible?

 

Hundreds of teams of really smart people have failed to improve outcomes and efficiency by putting physicians at triage.   In some cases, flow did not change.  In others, costs were too high.  We want to try it anyways.

 

 

Why would we bother?

Pros

It’s what we want for our families.  

When nurses and physicians need a medical opinion, they go straight to the nearest MD they trust.  Direct access.  All the non-value added steps removed.

Time equals quality in emergency medicine.  

The sooner we diagnose and treat patients, the higher quality of care we can guarantee.

Irresistible.  

The chance to radically improve flow and efficiency is just too attractive to ignore.  Imagine being able to see and treat even 10% of your patients out front – a chunk of patients would never enter the ED.  30 fewer patients and family members packed into the bowels of the ED seems reason enough to try it.

Fewer steps = lower cost.  

If we could exam and begin treatment without a lengthy pre-screen, triage and registration process, we would decrease the number of providers involved and decrease patient length of stay.  Staffing costs and length of stay directly impact efficiency.

Parallel processing beats sequential processing.  

Modern ED Triage is sequential.  It’s guaranteed to become a bottleneck unless an oversupply of staff continually support it.  A parallel RN-MD clinical stream right at the front door seems destined to succeed.

Cons

“If it ain’t broke…”  

We’ve ranked with the top 3 EDs in Ontario for time to physician initial assessment (PIA) for 18 months.  Our average PIA hovers just under 1 hour.  However, Voltaire said, “The good is enemy of the best” (approximately).  Unless we continually improve, we will slip back.

Everyone failed – why won’t you?  

Failed attempts don’t mean something is impossible.  As Thomas Edison said, “I have not failed.  I’ve just found 10,000 ways that won’t work.”  If a concept seems logical and irresistible, it’s worth trying again.  Also, St. Joe’s Hamilton seems to enjoy early success with their recent attempt at putting a physician at triage which inspires us to try it for ourselves.

We’ll let you know how it turns out when we try it in 48 hrs.  Please share your thoughts below – tell us what we need to know.  There’s still time to change what we’re about to attempt!

What You Need to Know to Improve Patient Flow at Triage

Modern triage = patient sorting + a boat-load of protocols and ‘value added’ steps.

Napoleon’s surgeon seems to be the first provider to try a sorting process for crowds of patients.  He wanted to quickly sort which wounded soldiers were most likely to return to battle, so he could provide care for them first.  Historical triage got soldiers back into action while seriously wounded soldiers were left to die.

Nice.

In the olden days of emergency medicine (30 years ago), patients could usually be seen soon after registration.  They were brought straight in, seen by a nurse and a physician soon after.  In the 1990s in Ontario, the ED became a favourite spot to park admitted patients when the inpatient wards became ‘full’ as defined by staff working on the wards.

Around this time, triage turned into primary care nursing for new arrivals and the crowd of patients warehoused in the waiting room.

This was never meant to be.

Triage must be rapid sorting or it’s not triage at all.

Long interviews, multiple forms, medication reconciliation, past medical history, allergy lists, infection control screening, extensive sets of vital signs, patient examination, wound inspection, and answering questions about waits, parking, directions and vending machine locations – modern triage redefined the term ‘triage’.

Maybe that’s a good thing?  Surely, all the added work being done by modern triage was started for a reason?  Maybe patients want to come to the ED to get a really thorough triage?

NO!

Patients come to the ED to get a diagnosis and treatment.  Anything that stands in the way of diagnosis and treatment does not add value for patients.

Triage should add value by getting patients to the care they need as quickly as possible.  We should resist anything that stands in the way of patient care.  Quality care depends on timely assessment and treatment.  Triage adds value only if it facilitates timely care.  Triage should never bottleneck flow; there should never be a line-up to see the triage nurse.

We must unload all the duties we’ve piled onto triage, if we are serious about improving patient flow.

If hospitals insist on running waiting rooms like a clinical areas, patients would be better served by assigning nurses to care for the patients in the waiting room instead of shackling triage nurses with non-value-added work.

Does triage add value in your hospital or does it delay care?  Is there a patient line-up for triage?  

Please click Leave a Reply or # replies below.

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: