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Staffing strategies help ED save more than $1 million a year
Tracking and monitoring of equipment yield additional savings
The ED at Catawba Valley Medical Center in Hickory, NC, has realized annual savings in excess of $1 million with the implementation of staffing strategies that involved the virtual elimination of contract staff and overtime for nurses.
The first step, involving contract staff, was begun several years ago and accomplished in eight or nine months, recalls Van Haygood, RN, MSN, NE-BC, administrator of emergency, post-procedural, and direct admission services. "As contract staff, they usually did not have any reason to be invested in the patients or the organization. They filled a spot, but just barely," he says. "It was much more important to create a sense of longevity."
The contracts were allowed to terminate. As each ended, a new permanent staff member was hired, until 16 were added. "Until we were able to successfully handle the patient load, there were members of our management team that worked clinically — up to 32 hours a week," says Haygood. The management team is a tight-knit group that maintains its clinical skills, he says, "so it really was not a huge deal."
The savings were considerable, he says. "We'd pay an agency $60-$62 bucks an hour, while PRNs at the top of the ladder make about $30," Haygood says. Before the shift, the ED was spending about $1.5 million annually on nurses, he says. That amount dropped down to about $750,000.
Overtime was eliminated. Tracy Hancock, RN, nurse manager in the ED, says, "I don't know if nurses were resistant, but they may have been a little nervous because a lot of people rely on overtime. But in May 2008, we began to talk to staff about the economy and what we needed to do as a hospital."
The nurses were told this change was now necessary to prevent the need for something more drastic a year or two down the road, Hancock says. Haygood says, "We basically said there would be no more overtime that was not pre-authorized." He notes that the department has cut overtime from 258 hours a week to about 10. "Once again, we put management back into some staffing roles and used more of our PRN folks," Haygood says.
In addition, they've done a lot of cross-training. "For example, we have nursing assistants in the ED who also can act as secretaries and as phlebotomists," he says. The hospital paid for their schooling, which he says was an initial investment that "has really paid off." Haygood is saving between $26,000 and $28,000 a pay period.
As for the nursing staff, "they actually own the decision now," says Hancock. "If we have a call-in and ask a nurse to pick up an eight-hour shift, they might say yes, but they may also tell me that might put them four hours overtime and suggest that I adjust staffing somewhere else." Other nurses might volunteer to be the first to leave at night, she says.
"They're actually happier. They may not have overtime, but they have a position," says Hancock. Haygood agrees. "We're the only organization within a 100-mile radius that has not had any layoffs," he notes.
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Managing supply chain adds savings
The ED leadership team at Catawba Valley Medical Center in Hickory, NC, has instituted several effective cost-saving strategies, including careful monitoring of small equipment.
"We now keep all small equipment in a Pyxis tower," says Van Haygood, RN, MSN, NE-BC, administrator of emergency, post-procedural, and direct admission services. "If Nurse X goes in to get a piece of equipment, our computerized tracking system enables us to run a report if something goes missing and we can figure out who that last person was." This, he notes, is "a really good incentive to be really careful with equipment and be sure it is put away."
They've also tried to limit the number of people who handle the equipment, adds Tracy Hancock, RN, nurse manager in the ED. "The hospital went to a low supply level, and we have a patient care coordinator who has taken over 'special order' supplies, like certain boxes of sutures ordered specifically," she says. Every day, this individual monitors such supplies and can designate one of the ED techs to obtain what is needed from another department, Hancock adds.
The staff are good at e-mailing if they see they are low on some supply, Hancock says. "It's really a team effort," she continues. "They may also mention it at staff meetings."
This "small" equipment can cause large financial losses if not monitored carefully, notes Haygood. "A portable otoscope or ophthalmoscope could cost about $800, and we were replacing a set every other month," he recalls. "Now it's been a couple of years since we replaced one."
The department also used to replace three or four sets of monitor cables a month, but it only has replaced one set in the last year or so, adds Haygood, noting that the losses were costing the department about $190 a month.
'Low-hanging fruit' a good place to start
If you're looking to cut costs in your ED, you might be able to obtain some quick, impressive results by picking some of that "low-hanging fruit" that can be found in nearly every department, says Gregory Henry, MD, FACEP, vice president of risk management, Emergency Physicians Medical Group, Ann Arbor, MI.
First, he says, the correct person should be doing the correct job. "There are plenty of things techs can do that nurses don't have to do," Henry says. "RNs should look at critically ill patients and not be putting people in rooms, taking their BP, cleaning up suture sets, or pushing patients to X-rays. These are tech jobs."
The bottom line is that "we need more techs than nurses," he says. "The number of critically ill patients is not always that high."
When it comes to supplies, it might be time to kick some old habits, Henry says. "There's no proof that saline, which comes in an expensive sealed bottle, is any better than tap water in cleaning wounds — not one ounce of proof," he says. "And nobody has ever shown that sterile gloves that cost a certain amount per package are any better than plain old latex gloves or nonsterile gloves you can get for 10 cents apiece."
Most EDs have too many supplies, Henry says. "Just cut out too many sizes of needles, too many anesthetic preps that go bad," he says. "This is the logical thinking you need to go to."
In addition, you should go through the entire pharmacy, "and drugs that are given out less than once a month need to be put in the main pharmacy," Henry says. "Otherwise, you'll have drugs passing their expiration date for no good reason." If you need a drug you don't have, "you should send someone to the pharmacy," he says. "Why should they keep going bad in your Pyxis?"
For example, "If I need antivenom for a cobra bite, I call the Detroit Zoo," Henry says. "How many cobra bites do you think we have?" The antivenom "is expensive, is never used, and most people do not know how to use it, so they have to look it up," he says.
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