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ED revamp: Team approach to care reduces errors, boosts patient and clinician satisfaction
Staff accountability and streamlined triage process deliver dividends
In 2008, there was plenty of evidence that things weren't working very well in the ED at St. Vincent's Medical Center in Bridgeport, CT. The leave-without-being-seen (LWBS) rate was at 5%, the average wait time to see a physician was over two hours, patient satisfaction was in the single digits, and the hospital recorded eight serious safety events in that one year alone.
"It was a very disjointed system, so senior management and the board of directors said things have got to change," recalls Frank Illuzzi, MD, FACEP, who is now the associate chairman of emergency services. To get things started, the hospital sent Illuzzi and Kathleen Woods, RN, MSN, CEN, the newly-appointed director of the ED, to participate in National Patient Safety Foundation Fellowship (NPSF) training, a year-long initiative of the Boston, MA-based NPSF that exposes participants to some of the best ideas in the country, says Illuzzi, noting that he and Woods returned to the hospital inspired and full of ideas.
"Hospital administrators told us to figure out how we could transform the ED into a highly reliable, highly efficient, safe place for our patients," says Illuzzi. "Kathleen and I both had ideas on what needed to be done, and we both felt that teamwork was going to be the key."
The approach Illuzzi and Woods adopted to rev the ED into a much higher gear has delivered on almost all counts. Patient satisfaction now exceeds 90% in almost all areas, average door-to-doctor times have been reduced from 126 minutes to less than 25 minutes, and, most importantly, the ED has reported no serious safety events in more than a year, reports Jody Gerard, MD, FACEP, CPE, the chairman and vice president of emergency services at St. Vincent's. (Also, see "To reduce wait times, streamline triage," below.)
"We have also seen a major shift in the market. Back in 2009, we were seeing about 175 patients per day. We are now seeing about 210 patients per day, and our year-over-year growth [in total census] has increased by 11%," says Gerard. "In the last month, we grew 24% compared to the prior year, and when we look at our primary service-area competitors, their growth has either been flat or down."
Establish zones of accountability
Illuzzi emphasizes that there is no magic bullet that can make a health-care setting safe and productive, but he and Woods recognized early on that their ED was operating in too many silos. "Each nurse and each physician was doing his or her own thing. There wasn't a lot of communication, and things were slipping by," he says. "There weren't a lot of redundancies to catch errors as they were occurring."
To correct the problem, Illuzzi and Woods divided the ED into a series of zones or neighborhoods, and assembled teams to be responsible for each area. For example, a typical team consisting of a physician, two nurses, and a secretary would be responsible for eight patients, explains Illuzzi. "What this engenders is a sense of ownership or responsibility," he says. "You are no longer a renter, you are an owner in your tiny little neighborhood."
In the previous system, any one of three physicians could basically pick up a patient's chart, and the nurse responsible for that area didn't necessarily know which physician was treating which patient, explains Gerard. "There was no clear accountability between what the patient, the nurse, and the physician were required to do," he says.
However, by assigning care teams to specific zones, there was no longer any question of who was responsible for caring for any particular patient. "Everything started to fall into place once we zoned the ED," says Illuzzi. "People were happier coming to work, they felt more connected with their patients, and they spent less time looking for charts and looking for the responsible physician or nurse. Things just started to [improve] from there."
In addition to clarifying responsibilities, the team approach also created a system of checks and balances so that any errors on the part a physician, nurse, or technician are much more likely to be picked up by another member of the team, says Illuzzi. "When you work in teams, there are redundancies that occur because you have your teammates constantly looking over your shoulder, anticipating your needs, and anticipating what is going to happen," he says. "They have the ability to provide feedback when untoward things happen, so you have a lot of things happening in parallel. There are layers with each interaction, and errors are greatly reduced."
Alternatively, if you are not working in teams, then essentially what you have is a system that works via a series of steps, and if an error occurs at one of those steps, there is a chance that the error will cause harm to the patient, explains Illuzzi.
The hospital has had no serious safety events in more than a year, but administrators keep the issue high on everyone's priority list by holding a "safety huddle" every morning at 8:15. "All the managers and senior leadership meet in the hospital library and we basically review the previous 24 hours," says Illuzzi. "If there are any issues that pop up, we let the appropriate departments know, and we have to have feedback within 24 hours as to what the root causes were and what the fix is."
Keep key metrics in focus
A similar process takes place in the ED every day with the "Daily Census Report," a collection of data compiled by Gerard that always highlights the number of days since the last serious safety event occurred, and a range of other key metrics such as average door-to-doctor times, the number of patients that LWBS, and the number of patients seen. In addition, the report highlights any successes that the ED has experienced in the past 24 hours, as well as opportunities to improve, explains Gerard.
"The Daily Census Report is sent to all senior leadership, every nurse who works in the ED, every physician who works in the ED, pastoral care, finance, registration, case management, and security," he says. "They are not all interested in every element of the report, but because we are careful to address something in each of those areas, people are interested in opening up the report to look for themselves."
The idea is to keep the administration's goals and priorities on the front burner while also quickly highlighting any deficiencies that need to be quickly corrected. "We have created in the culture an awareness of patient experience, safety, throughput, success, and opportunity," says Gerard. "This allows senior leadership to understand on a day-by-day basis how the hospital's front door which is the ED is feeding the institution and also how it requires support from the institution."
The metrics are all easily retrieved from the ED's electronic health record, but Gerard also includes in every report what he refers to as a patient-experience story. For example, one case he was planning to write about for inclusion in the report as this article went to press dealt with a 31-year-old patient who came into the ED complaining of chest pain. The patient was triaged quickly and given an EKG, but then waited for about an hour before leaving to go to another ED, where he also had to wait for a long time, says Gerard. The patient's mother then wrote a letter of complaint to the hospital, suggesting than an hour-long wait is too long for a patient with chest pain.
Gerard's take on this situation is that ED staff should understand that even a young patient with chest pain may be afraid that he is dying, so it is important to be cognizant of the anxiety the patient is feeling when he arrives in the ED, and to consider if there is something you can say or do to reassure him that he is safe even though it may take a while to get all the testing completed. "That might have been enough for that patient," says Gerard. "It had nothing to do with the diagnosis or identifying what the patient needed in a rapid and efficient way."
Fix the process first
Response to the Daily Census Report was not all positive, at least initially, because many of the physicians were not comfortable being measured, says Gerard. However, he emphasizes that people are drawn to read the report precisely because there could be something about them included. "We don't talk about any individual, but we talk about the team," says Gerard. "If there is an area in which we failed, in most instances, it is a team failure, not an individual failure."
Moreover, the report provides some added information to physicians and nurses who work in a setting where they often receive very little follow-up on what has happened with their patients. "We come in, we do the best we can, we treat our patients as efficiently and competently as we can, and then we go home without really knowing what happened," says Gerard. "The report allows physicians and nurses to have some closure on their day, so that when they come in the next day, they can be prepared to focus on the things we identify [in the report] as needing focus. That is, frankly, the responsibility of leadership: to set an agenda, to set priorities, measure them, and then feed them back."
Gerard is quick to emphasize that the Daily Census Report would not have been effective without laying the groundwork first. "I have tried to do this in other places, but there is a difference here, and the difference is the foundational team formation," he says. "You can take a process like this and lay it on top of an ED that has a 30% nurse vacancy rate, local physicians coming in and out, inadequate leadership, and no active senior administration engagement, and it will fail."
To reduce ED wait times, streamline triage
Working in teams can help improve safety and accountability, but it is not necessarily going to be successful at lowering wait times unless you take steps to streamline your triage process as well, observes Jody Gerard, MD, FACEP, CPE, the chairman and vice president of emergency services at St. Vincent's Medical Center in Bridgeport, CT. This, in fact, was the next step administrators at St. Vincent's turned to once they had implemented a team approach to emergency care.
"At that point, there were still four- to six-hour wait times because the nurses were still doing what many institutions across the country do, which is starting advanced triage nursing protocols," says Gerard. "They were putting in IVs and drawing blood on pretty much every patient."
Concluding that not all patients needed to undergo these steps, ED administrators moved a physician-nurse-tech team to the front of the ED and created a no-wait process. Under the new system, patients who come into the ED undergo a quick registration so that a patient arm band can be created. Then, rather than going through a long checklist of triage items, a highly-trained nurse will determine whether a patient is sick (Emergency Severity Index [ESI] 1 or 2), not sick (ESI 4 or 5), or in between (ESI 3), explains Gerard.
All ESI 1 and 2 patients are brought back into the ED for further evaluation by a clinical team; however, the ESI 4s and 5s are immediately seen by the up-front physician-nurse-tech team in a "no-wait" area. "These patients never go back to a bed, never need to get undressed, and don't need an IV or any blood drawn. They need only minimal resources," says Gerard. "They can be seen, treated, and released typically within 30 to 45 minutes."
The ESI 3 patients do not appear sick, but may need more than one or two resources, adds Gerard. For example, a patient who is dehydrated and needs an hour or two on IV fluids, or an asthmatic who has run out of treatment at home and may need a couple of treatments, would fall into this category. These patients will be moved to an "express care plus" area, staffed by a physician's assistant (PA) and a nurse, to receive one or two hours of care and the opportunity to be evaluated again, he says. "If their condition gets worse, they go back to the main ED, and if it gets better, they can be discharged with the physician in the "no-wait" area supervising the PA."
The new triage system has dramatically reduced the average wait time, but it has also boosted efficiency and reduced costs. "Just our IV equipment costs have decreased by $84,000 per year," says Gerard. "And our FTE [full-time employees] per patient rate has declined from roughly 18 FTEs per thousand patients seen to 15 FTEs per thousand patients seen."
Lower wait times have produced increases in patient satisfaction, but administrators have found that the hospital has to work harder now to please. "In the past people would complain that they had to wait for four hours in the ED, and now people come in complaining that they had to wait 30 minutes in the 'no-wait' ED," says Gerard. "Our patient satisfaction has now begun to decline, but it is declining because the expectation of the community has changed."