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'Attitude adjustment' is key to ED success
Presenting patients get a bed in 3 minutes
In the face of steadily increasing volumes (13,000 between 2008 and 2009), the ED at Peninsula Regional Medical Center in Salisbury, MD, has improved all of its operating statistics, achieving a 'door-to-bed' time of three minutes and a door-to-doc time of 21 minutes.
While such a performance could not have been accomplished without more efficient processes, the ED leadership team insists that the single most important element in their success has been a change in the way physicians and nurses relate to each other.
"We had some leadership changes 18 months ago with a renewed emphasis on our relationship and teamwork with nursing and the hospital," says Clark Willis, MD, medical director of the ED. "Most of the positive changes that have occurred, in my opinion, are process, structure and throughput changes that resulted out of that collaboration." Willis says it is "amazing" what can be accomplished when physicians and nurses link hands and work together, instead of blaming each other and pointing fingers.
Susan Castrignano, RN, BSN, nursing director, agrees. "A lot of it had to do with leadership," says Castrignano, who adds that she and Willis came to their positions about the same time. "When the staff saw we actually talked to each other and were on the same plan and shared the same ideas, and that we had support for each other, support from the physician group to nursing and vice versa, little by little people saw you as a leadership team and not me representing the nurses and he representing the physician team," Castrignano says.
One simple but important change involved the structure of staff meetings, she says. "Now we have one big meeting, whereas we used to have a staff meeting for nurses and a departmental meeting for doctors and some nurses," Castrignano says. "Now we are all in one big room together. We hear the same message at the same time."
Willis says, "We sat down and talked about what we thought made a difference." After an ED expansion, "we had more space, new servers to run the EMR [electronic medical record], but we both agreed that we had to make a renewed initiative of working together," he says.
In the past, there was much more division about who was responsible for different activities and whether errors were the doctor's fault or the nurse's, Willis says. "In trying to focus on how we could work better together, we eliminated job-title-specific details," he says. "Meetings were more about everybody seeing the bigger picture of where we were headed and what we were trying to do. The key questions became what was best for the patients and how we could best serve them, regardless of whose area it was."
For more information about teamwork between ED nurses and physicians, contact:
'Line at the door' is tackled first
When the ED leadership team at Peninsula Regional Medical Center in Salisbury, MD, set out to improve throughput, the first thing they tackled was the line at the door, says Clark Willis, MD, medical director.
"Patients were lined up at one window trying to get registered and triaged," Willis recalls "The attitude was that we didn't 'own' the patient until they got past that wall."
Process changes to address this issue included putting a greeter in the waiting room to be sure patients with more urgent needs were seen first and streamlining the triage process so patients would get to treatment more quickly. (The greeter also improves clinical care. See clinical tip, below.)
Susan Castrignano, RN, BSN, the nursing director, says, "The ED had been expanded from 19,000 square feet to 41,000 square feet, but as much input as we had into the design, when our volume went up we still had issues. Instead of a full triage, if there was an open bed we started bringing the patients straight back. You could bring four or five people back at the same time, and it all happened in parallel."
To help make this possible, changes were made to the EMR screen to prevent nurses from performing a full triage and directing them to just do a "mini-screen," Castrignano says.
"The content of the triage was not changed, but the team felt it was important to separate the screens and have the triage nurses do the first initial screen and the primary nurse who would be taking care of the patient the second part, which contains the past medical history and medication reconciliation," she says.
The traditional culture of the staff was to do as much as possible in triage and not to dump the work on the primary nurses, Castrignano says. "But when the question came up as to what was best for the patient, and the goal is to have the patient see the provider, the majority of the nurses were supportive about the process change," she explains.
As with all of the changes made in this ED, teamwork was a critical element. Willis says, "We involved the nurses in the decision-making. We had a focus group process improvement, rather than just pronouncing the change."
The nurses received one-on-one training from other nurses. They walked through the new screening process and seeing how to get patients back to the bed more quickly. "The doctors were recipients of education, too, since they had to hop in and see those patients with the understanding that they may not have been completely triaged," Willis says.
The new attitude of cooperation manifested itself when a problem arose with the express care unit. "When we started to bring patients straight back, we had to protect express care, because staff tended to grab mid-level people to protect the doctors," Willis says. "They were poaching from express care to fill their own needs. We agreed to protect express care staff; that doctors would not pull mid-level staff, and nurses would not pull nurses or techs."
The result? Despite the fact that express care saw a 21% increase in volume, its throughput went from an hour and a half to under 60 minutes.
A greeter can avert waiting room tragedies
Want to prevent your ED from becoming one of those headlines blaring "Death in the waiting room"? Put a greeter out front, says Clark Willis, MD, medical director of the ED at Peninsula Regional Medical Center in Salisbury, MD.
"Having a physician's assistant or secretary there when patients first present make them our eyes and ears," Willis explains. "Without that you can literally have someone fall over in the corner. This way, they won't sit at the end of the line in failing health."