To the casual observer, med/surg units today may resemble an airport bustling with constant arrivals and departures. Shorter lengths of stay and increased demand to improve throughput throughout the hospital place tremendous pressure on med/surg nurses.
|SMOOTH OPERATORS: Express Admissions Unit nurses at The Medical Center of Aurora have helped reduce holding time per patient in the ED by 44 percent and decreased the number of patients experiencing a hold in the ED by 50 patients per month. courtesy The Medical Center of Aurora
Recognizing the stress inherent in this situation, savvy nurse leaders like Thomas Johnson, BSN, RN, admissions coordinator at Desert Regional Medical Center, Palm Springs, CA, have spearheaded organization-wide efforts to keep things moving.
Admissions Nurse Approach
"Our Patient Flow Committee meets every 2 weeks with representatives from the emergency department and the nursing units," Johnson said. "We talk about how we can make the patient experience better from ED triage through admission to an inpatient bed. Over the past year and a half, we've added admissions nurses to the staff in the ED, and we've consolidated our electronic medical record system so everyone is entering and retrieving data from the same records rather than printing and re-entering information.
"We may have 10 med/surg patients in the ED waiting for a bed, and that makes it difficult to stay under the national average of 6 hours and 41 minutes from the time patients arrive in ED triage until they get into a bed on the med/surg unit," Johnson continued. "Admissions nurses staff the ED 24 hours a day, and they take care of the bulk of the admissions process for patients who are ready to go upstairs. The admissions nurses complete the nursing admission histories, core measures form and belongings list, and do the medication reconciliation paperwork as well."
A good admissions nurse is a people person, one who likes interacting with others.
"They have a lot of experience, and they're comfortable sitting down at the patient's bedside in the ED," Johnson said. "They often walk a patient upstairs to the floor and provide hand-off information to the med/surg staff. I've found med/surg nurses are more willing to take a patient sooner if they know the bulk of the paperwork is already done."
Johnson has formed collegial relationships that help smooth the way for admissions to med/surg.
"If I have an open bed and am only waiting on orders, I'll walk over to the ED doctor and ask for those orders," he said. "We installed dedicated phones for the clinical managers on each floor, so I can call and share information about waiting admissions directly to that nurse. That communication helps patient flow and keeps everyone on the same page."
Influence of Magnet
Carol Gregory, MBA, MSN, RN, NEA-BC, vice president of patient care services and chief nursing officer at the Medical Center of Aurora and Centennial Medical Plaza in Aurora, CO, described how nurses at her facility worked together to expedite admissions to their med/surg units.
"The Magnet culture brings new knowledge into the organization and encourages innovative approaches," she said. "At one point a couple of years ago, one of our busy surgical units experimented with the use of an admission nurse who worked staggered shifts to cover the busiest times of day. From there, we expanded into a much larger concept, opening an eight-bed Express Admissions Unit in February 2010 that has been wildly successful."
Staffed from 11 a.m-10 p.m. each day, the express admission unit has reduced holding time per patient in the ED by 44 percent and decreased the number of patients experiencing a hold in the ED by 50 patients per month. "The admission nursing history was taking 45 minutes to an hour on the med/surg units, bogging down the nurses who were caring for other patients," Gregory said. "Now, the express admissions unit nurses complete that history and the nurses on the units are thrilled to welcome patients to their floor once that paperwork is completed."
Two years ago, the Medical Center of Aurora implemented a direct-admission process for patients coming from a physician's office.
"The primary care physicians couldn't get their patients moved from the office to a hospital bed expeditiously, and sometimes they would send them to other hospitals," Gregory said. "We now have a designated case manager who carries a dedicated phone, sets up a three-way call including the hospitalist and referring physician, and escorts the patient from the front door of the hospital to the admissions office. She then brings the patient to the express admissions unit, so the patient never even sees the inside of our ED."
An Engineering Approach
At Scripps Memorial Hospital, La Jolla, the length of stay on various med/surg units runs between 3 and 5 days, and it takes nurses with good computer skills anywhere from 60-90 minutes to complete the admission process. Patients come from the ED or surgery with a completed history and physical, as well as an initial medication administration report. "The primary nurse starts the Nursing Admission Assessment Screen, orients them to their rooms and brings in the charge nurse to review the patient booklet and expectations," described Holly De Falco, BS, RN, CMSRN, patient care manager of the surgical acute unit. "If the primary nurse has enough time, she does it on her own; if primary nurses need a hand, they can call in the charge nurse. The primary nurse may also ask for assistance from the clinical mentor, an advanced nurse with a minimum of 5 years experience who watches over the bedside nurses and helps close any gaps."
De Falco and other nurse leaders are working with engineering students from the University of San Diego to gather and analyze extensive data about that process. "We want to see how we can use the nursing resources we have efficiently and effectively to improve patient flow, especially with direct admits, which are the most time-consuming population," she said. "That decision may or may not include dedicated nurses for admissions and discharges."
Sandy Keefe is a frequent contributor to ADVANCE.