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Bar-coded patient IDs cut LOS nearly one hour
Identification of patients precedes registration
[Editor’s note: A new report from the Urgent Matters Learning Network, Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments, identifies best practices from 10 hospitals selected as participants in an initiative to help hospitals eliminate ED crowding. Each participating hospital developed and implemented strategies to improve patient flow through the ED and to reduce overcrowding. (See resources, below, for information on how to obtain the report.) In our November issue, EDM featured strategies and methods employed at Grady Hospital in Atlanta and University Hospital in San Antonio, which made their programs successful. We continue our series with this article.]
The "Urgent Matters" team in the ED at University of California San Diego Medical Center has dropped its length of stay by 50 minutes, its left-without-being-seen patients from 9% to less than 4%, and its wait times for patients eventually admitted from 45 minutes to fewer than 15 minutes.
How did they do it?
"We developed a rapid-entry process — a modified form of bedside registration — which basically consisted of bar coding" patient identification bands, says Ted Chan, MD, associate professor of clinical medicine and head of the ED team.
His team — which included the head nurse, the ED’s informatics director, the head of the ED, and the head clerk, as well as several nurses — saw what Chan calls "silofication" in the process. "Patients would sign in, wait for triage, wait for registration, wait for there to be an open bed, and each element had a period of waiting associated with it," he explains.
The new process was introduced in August 2003. "We turned something that was done only on special occasions into a routine process," says James Killeen, MD, informatics director for the ED. "We developed a point-of-entry quick registration, which could plug into the electronic medical record that I designed."
The team integrated the electronic record with the hospital system, Chan explains, so when patients signed in, there was an automatic search for a medical record (MR) number. "About 80% of our patients already have one," he notes.
If a patient didn’t already have one, the computer generated a new one for them, including name, date of birth, and Social Security number, if they had one. "This was linked to a bar-code wristband printer, so by the time the individual got to triage, they had their ID number on their wristband," Chan says.
By doing that process, the EDs have the patient established, Killeen adds. "We can send off labs, X-ray requests, and results information immediately," he says.
Once the patient gets to triage, one of two things can happen, Chan continues. "They could go to any open bed; we have directed our triage nurses to fill any open bed," he says. "Or if there was no open bed, the nurse was to contact a physician to come to triage and get ancillary tests done — i.e., [blood work], X-rays."
The ED had tried bedside registration in the past, "but at that time, you still had to have registration done before X-rays or blood tests or radiology could be performed," Chan says. "In this system, because you have an automatic search at sign-in for the MR number, or one is generated, you could get all of that done, and the patient could even go under registration after discharge, if he had to."
Another thing that sets this system apart is that there are no physicians on duty in triage. "Our patients go to triage if they can’t get to an ED room, and most studies that have looked at this method have spent money to put a physician in triage, but we did not do that," he continues. "We decided that since such a small percentage of patients did not get open beds, the nurse could always get a doctor if one was needed to get tests going."
Killeen says that successful culture change was a critical factor in the positive results of the project.
"We got a lot of ideas from the Robert Woods Johnson people about education, re-education, and giving staff updates as to how we were doing, so they had knowledge of not just what they were doing but what everyone in the ED was doing, and how efficient they were becoming," he explains.
One good example is dealing with patients in the waiting room, Killeen says. The managers helped engender buy-in for the project by sharing information, he says.
"The nurses, as well as the administrative people who at the time were registering patients, became more aware of how overwhelmed their colleagues felt," he explains. "They better understood that now, instead of a serial process where everyone stood in line, we were making a parallel process, so everyone could be brought in when they needed to be."
For information on the Urgent Matters project at the University of California San Diego Medical Center, contact:
A free copy of the report, Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments, can be found at www.urgentmatters.org. A link to the report is found under "Latest News."
Urgent Matters is accepting applications from hospitals to participate in Learning Network II, an intense, yearlong collaborative to improve patient flow and reduce ED crowding. A new group of selected hospitals will receive consultation from experts, access best practices, measure and improve patient flow, and learn with other leading hospitals in the country. On-line applications are due Dec. 10, 2004. For more information, go to www.urgentmatters.org/LearningNetworkII.