PHILADELPHIA - Leaving the emergency department (ED) before treatment presents a danger to both patients and hospitals. Patients risk worsening health when they are not properly diagnosed and treated. High left-without-being-seen (LWBS) rates correspond to ED overcrowding, a scenario that angers patients and makes it difficult for staff to deliver appropriate care.
Additionally, LWBS rates are now a quality metric assessed by the Centers for Medicare and Medicaid Services. Hospitals are required to report LWBS numbers, which are accessible to the public. Patients cannot always choose their ED, but when they do, would they go to a facility with high wait times?
In first quarter 2015, Thomas Jefferson University Hospital (TJUH) in Philadelphia had an LWBS rate of 5.7% and a door-to-provider time of 43 minutes. The national average for LWBS was 2%. The hospital set a goal to lower its LWBS to less than 2% and its door-to-provider time to less than 20 minutes.
Exceeding those goals is the reason the emergency department at Thomas Jefferson University Hospital was named the ADVANCE for Nurses 2016 Best Nursing Team.
Leading the Charge
The Emergency Department at TJUH is a bustling place that takes up an entire city block. It has 54 beds and its staff evaluates approximately 62,000 patients each year. The most common presenting complaints are orthopedic injuries, chest pain, abdominal pain and viral symptoms. Similar to other EDs, the busiest times are weekdays between 2 p.m. and 10 p.m.
In 2014, Jefferson leadership created a blueprint for strategic action (BSA), which provided direction to secure Jefferson's future and defined how to achieve success. In support of the BSA, ED leadership developed ED 2.0, a strategic initiative aimed at transformation and focused on reducing LWBS rates, door to provider times, and improving patient and staff satisfaction.
"We adopted it as our mantra and challenged ourselves to become a more patient- and family-centric ED," said Stephan McDonald, MSN, manager of the emergency department. That slogan-Patients and Families First-is prominent across the emergency department. "Jefferson wants to be the best in all areas," McDonald said. "It's a privilege to care for 62,000 people in the Philadelphia area, and we don't take that lightly."
Nurses as Champions
The ED staff already knew the high quality of medical care provided at the hospital, since many of them receive care there. "We receive a lot of referrals and receive a good deal of people who travel a great distance to come for the Jefferson brand," McDonald remarked. The ED sees especially high rates of neurological and orthopedic patients brought in from other facilities. Improving the patient experience in the ED, where many patients are introduced to the hospital, was the lofty goal.
Before the ED 2.0 project even got off the ground, the department had tremendous support from hospital leadership. Physician leadership in the department was extremely engaged in the process and redesign. "The support was the only way we could institute such radical change," McDonald acknowledged. "We set our own path and looked at best practices across the country."
McDonald cited the Emergency Department at University of Colorado, which he and other staff members visited to prepare for ED 2.0, as a model for effectively moving patients through an ED.
Prior to the kickoff of the initiative, the department staff held countless meetings. A conference room was turned into de facto office space where anyone interested could learn about the processes and provide input. As the primary front-line patient care staff, nurses' opinions were highly considered. "We wanted to leverage the amazing nursing staff and we really worked hard to engage them throughout the process. They were at the table and their voices were heard," McDonald explained.
Improving Patient Flow
The first sign that something is different at TJUH's ED is the absence of traditional nurse triage. When an ambulatory patient first comes in, he or she checks in with the registrar and "Pivot RN," who does a cursory triage based on appearance and chief complaint. "The Pivot Nurse has algorithms to follow," explained Susan Cissone, MSN, administrative supervisor in the emergency department. Those algorithms determine if the patient goes gets an ED bed immediately or goes to the intake area.
Four intake rooms are staffed with a physician, scribe, vitals tech and mover techs. After vital signs are taken, the physician performs a 5-minute assessment. That determines if the patient is discharged, moved to the Fast-Track ED (staffed by a physician assistant or nurse practitioner) or moved to the main ED for further treatment.
"The goal is anyone who will stay in the emergency department less than 2 hours goes to Fast Track," Cissone said. Patients with low acuity or minor injuries are sent there. Staff members wear headsets to facilitate communication with one another.
The main ED houses Intake, two Trauma Bays, the A/B Areas with patient beds, and one unexpected feature. "We have our own OR in the ED. Very few Level I trauma centers have that," McDonald said. While the preference is transferring patients to the operating rooms in the main hospital, he said, "If you're hemodynamically unstable with penetrating trauma, the ED and trauma team can take the patient directly to our ED OR and attempt to resuscitate the patient and perform lifesaving surgery immediately." The ED OR is for the most critical trauma cases and is typically used less than 20 times per year.
Less Waiting Means Happier Patients
With ED 2.0 and the new intake model, Jefferson has pretty much eliminated the external waiting room. An internal waiting area is opened when the ED is at capacity. With the physician intake model, patients are typically evaluated by a physician before waiting in the internal waiting room. To ensure that patients in the internal waiting area are well cared for and informed, they staff the area with a nurse and technician. "Your wait time should be as productive as possible," Cissone explained.
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Located strategically throughout the department are real-time dashboards designed by TJUH's IS&T application development team; these provide up-to-the minute data on a number of key performance metrics. The dashboards track how many patients are waiting and the average wait time; the current census; and the longest length of stay in Intake, Fast Track and the A/B Areas. Colors change when the emergency department reaches saturation, triggering action plans.
"Nurses should keep the patients at the center of all their decisions," Cissone noted. The flow of the ED ensures that patients are where nursing staff can see them and give them what they need. If patients aren't moved efficiently through the system, it creates redundancies-an additional stress for nurses.
Coordinating to Hit Goal
Communication is at the heart of the redesigned workflow. "There's an enormous interdependent relationship, especially between the nurses and the techs and the nurses and the physicians as it relates to changes in patient status," McDonald said. Nurses interact with physicians, social workers, case managers, pharmacists, radiologists, the transport team and other departments on a regular basis. Those relationships rely on information sharing and are critical to patient throughput.
"Anyone looking to change their intake model needs to be bold," McDonald said. Challenging the status quo is always a formidable undertaking, and it needs support from front line staff, physicians and leadership. "Including nursing staff in decisions led to our success," Cissone emphasized.
Thomas Jefferson University Hospital's bold vision paid off. With the implementation of ED 2.0, they saw immediate success with a 0.42% LWBS rate in the first week, far exceeding the original goal. These efforts have been sustained to this day with most recent quarterly data (Q4 2015) showing a 0.8% LWBS rate and an 11-minute door to provider time. Patients and families have appreciated the changes in the ED. Patient satisfaction scores have never been higher.
"We are extremely proud of what the team has accomplished. While ED 2.0 was a call to action to ensure we were putting the patients and their families at the center of all we do, it was also a tremendous example of the power of teamwork and staff engagement," said Joseph Anton, MSN, RN, vice president of clinical and support services.
Danielle Bullen is a staff writer. Email her at: firstname.lastname@example.org