By Debra Wood, RN, contributor
July 28, 2010 - Despite the steps many hospitals have taken to improve patient flow, patients are spending more time in emergency departments, but satisfaction with their care remained about the same for 2009, according to findings from the Press Ganey 2010 Emergency Department Pulse Report.
“There are organizations working to improve the total time patients spend in the emergency department, but there are others who are succumbing to larger volumes or inefficiencies within the organization,” said Deirdre Mylod, vice president of hospital services for Press Ganey of South Bend, Ind. “We’re hearing great stories, because some folks are being quite successful, but that doesn’t mean that nationally there aren’t issues with wait time.”
The findings are based on evaluations of 1.5 million patients treated at 1,893 hospitals. An analysis of actual time using a patient-tracking system found a strong correlation between patient self-reporting and reality.
The research firm found patients spent an average of 4 hours 7 minutes in U.S. emergency departments (EDs) in 2009, an increase of 4 minutes from 2008 and 31 minutes since 2002. Iowa had the shortest average time spent at 2 hours 55 minutes, and Utah had the longest at 8 hours and 17 minutes, which was more than two and half hours longer than the next-worst state, Kansas.
More than half of the states improved wait times or kept increases to a minimum. Nevada hospitals improved the most, reducing average wait time by 66 minutes since 2008.
Press Ganey found patient satisfaction remained about the same as the prior year, after a five-year upward trend. Patients arriving between 7 a.m. and 3 p.m. were happier with their care than those patients arriving after 3 p.m. Weekend arrivals rated their care higher than weekday patients. Patients who stayed less than two hours gave higher marks to their care than those who waited more than two hours.
Communication about delays seems key to keeping the satisfaction scores high despite the wait times, Mylod said.
“Patients need to feel more informed that you haven’t forgotten about them,” Mylod said.
Christina Dempsey, vice president of clinical and operational consulting for Press Ganey, said the ED is at the mercy of the inpatient census of the hospital. Patients must go to the right unit.
Paige Jackson, RN, MSN, credits a treat-and-release program and nurse leadership attention to throughput with decreasing ED wait times.
“Even though a lot of people are working on the emergency department, unless you can get those patients into the inpatient side, you will have long wait times,” Dempsey said. “You have to get rid of the peaks and valleys you see in the inpatient census, which means working on things like the elective surgical schedule.”
Speeding throughput
Many hospitals have found ways to decrease ED wait times and length of stay, including correcting overall bed issues.
Covenant Health System in Lubbock, Texas, improved hospital-wide throughput when senior nurse leaders, including the chief nursing officer, began rounding twice daily to identify delays or issues related to patient care. Paige Jackson, RN, MSN, Covenant ED nurse manager, said this has helped in securing a quicker admission for those ED patients needing inpatient care.
In addition, the hospital opened a “treat-and-release” unit, commonly referred to as a fast-track area, to streamline care for clinic-acuity patients. That dropped the average turnaround time to 75 minutes, which decreased the overall ED length of stay by 30 minutes.
Teletracking at Children’s Healthcare of Atlanta helps nurses monitor bed availability. Nurses caring for a patient awaiting admission fill out a “fax and fly report,” with all of the pertinent information. They send the patient to the floor via transport 15 minutes later.
Marianne Hatfield, BSN, RN, CENP, credits the ED’s Team Assessment Pull Process with shortening the time a patient spends in the ED.
“This process was entirely designed by the front-line staff and physicians,” said Marianne Hatfield, BSN, RN, CENP, system director of emergency services for Children’s of Atlanta. “They find the waste in their own process and figure ways to cut it out and become more efficient.”
Children’s Healthcare of Atlanta had enlarged its emergency department in hopes of paring length of stay, but instead the times become longer, so the facility employed lean methods of continuous improvement to redesign processes and created a Team Assessment Pull Process (TAPP).
“You pull work to you as you are ready to do work,” Hatfield said.
A nurse and physician complete the initial assessment together, eliminating order confusion and allowing immediate discharge if no other treatment is needed. The nurse is not available for other patients until he or she starts the orders on that assessed patient. Everyone works at a slow and steady pace. The patient only tells his or her story once.
In 2009, Children’s of Atlanta increased its volume without adding staff. The door-to-doctor time dropped by 36 percent compared to the same period last year -- 28 minutes compared to 44 minutes in 2008 -- and the overall length of stay decreased by 13 percent. Length of stay has fallen from 153 minutes to 125 minutes.
Saint Mary’s Regional Medical Center in Reno, Nev., strives to discharge inpatients by 11 a.m. to ensure beds are available as the ED becomes busier. Case managers round with physicians on the telemetry and critical care units to help facilitate transfers, said Shelby Hunt, RN, MHA, CEN, director of the emergency room.
In addition, Saint Mary’s established a rapid medical evaluation process, in which a mid-level provider or a physician in the triage area assesses patients, orders lab work or imaging studies, and then sends the patient to an internal waiting area if a room is not available. When the ED is at capacity, higher-acuity patients start with a laboratory draw and imaging studies, if ordered. Nurses obtain urine specimens on nearly all patients. The ED includes a point-of-care laboratory and an X-ray facility. Physicians order electronically and a tracking board helps nurses monitor where patients are in the process.
Changing flow within the ED
Eileen Yost, RN, at Roosevelt Hospital in New York, reports the hospital sped up the ED process by bringing all patients back into the department after a quick triage.
Roosevelt and St. Luke’s Hospitals in New York redesigned their processes. Nurses now complete a rapid patient identification, starting registration and a quick triage. Patients then go directly to the emergency room or the fast-track area. A nurse/physician team meets the patient and begins an assessment. The mini-registration allows staff to immediately begin lab work or imaging studies.
“Once you are triaged, you do not get sent to the waiting room,” says Eileen Yost, RN, nurse manager for the Roosevelt Hospital emergency department, which treats between 230 and 250 patients a day. St. Luke’s sees between 350 and 400 patients daily.
Average door-to-doctor time is 25 minutes, down from 70 minutes seven years ago, regardless of triage level. Door-to-decision time is 3.5 hours.
“The highest liability is patients you have triaged and are sitting in the waiting room,” Yost said. “Patients appreciate [the new system].
They might have to wait, but they are a step closer. They know what is going on. And we are not missing anything.”
Ochsner Medical Center in New Orleans has taken a different approach, also with good results. It established a “Q-track”system. A nurse screens patients using a five-level triage. A provider takes a quick look at less-acute patients and orders lab work or imaging. Then the patient returns to the waiting room until results comes in. A nurse stays in the waiting room and can bring a patient whose condition is changing back into the ED. About 60 percent of patients go through Q-track.
“We have a faster turnaround time, and we have a little more capacity,” said Rosa Judd, unit director of the emergency department at Ochsner Medical Center.
Ochsner set a goal of 30 minutes from door to doctor and it typically meets that objective. Length of stay has decreased.
Children’s Hospital and Health System in Milwaukee began its lean process improvement program about a year ago, assessing processes, mapping people’s movement in the department and assessing supplies to ensure they are in the right place when the nurse needs them, said Mary Goeghan, RN, MSN, emergency department/trauma center patient care manager. The hospital hired a flow coordinator to monitor flow between the two sections of the ED. One area handles less-acutely-ill patients.
Length of stay has declined by about 10 minutes, but the hospital has cut its “left without treatment” from 2.7 percent in second quarter 2009 to less than 1.5 percent this year. In addition, a greater consciousness about goals and improving throughout has led to improvements.
“Staff are looking at metrics and averages,” Goeghan said. “They can see it and wonder what happened [in a certain case]. People look at it more.”
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