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Marion General ED Emphasizes Timeliness of Care

Gail Loadman

November 25, 2009

A question was raised during the last employee meetings as to why our emergency department does not have a system in place to take care of those patients who are not in need of x-rays, lab tests, scans, etc., but who truly do need to be seen by a physician for pain, infection, fever, etc. Well, actually, our ED has several tools in place to take care of our “less than life-threatening” emergency patients.

Over the past eight months, Marion General’s emergency department has implemented what is called “nurse first” during their busiest times. This means exactly what it says … a nurse is the first person a patient sees when they enter the emergency room lobby entrance. By having an emergency nurse stationed at the door, doing an initial assessment of patients, the flow of care is much quicker. This nurse decides if a patient needs to go immediately to the triage nurse, or if they need to go immediately to an ED room … or if they can wait for a bit.

According to Gail Loadman, director of clinical operations, “Many patients may not need to be placed in a room or even a bed, and by having an experienced emergency room nurse stationed at the entrance door, that decision can be made quickly.” The ED staff realizes that even though a patient may qualify for a short stay in the department on initial look, many times it will turn into more than that. And of course, at that point in time they would be eligible for a room with a bed and more privacy. Also, when it becomes very busy in the lobby, the “nurse first” will move to the second triage area adjacent to the main triage. At this point, both triage nurses assist the ED greeter by visually performing “across the room” assessment of incoming patients. Once all patients are triaged, “nurse first” returns to the front desk.

Another plan in place for taking care of patients during the busiest times in the emergency department … sometimes called “treat and street” … is put into effect from 3-7 p.m., Sunday through Thursday. “Surprisingly, these are some of our busiest days and hours,” Gail says. “And sometimes the surge of patients results in a bottleneck of patients for the night shift coming on duty.”

This plan involves having a physician’s assistant (PA) staff an area set up in an ED hallway where patients who do not require a bed, or who could sit on a cart or chair, but do not need to undress, lay down, or require additional extensive testing, can be seen. Even now, during surge times, they can implement this plan. “During October, we had this plan in effect most hours of the day due to the constant surge of patients,” says Gail. “It works very well for complaints such as toothaches, earaches, ankle injuries, and other relatively minor complaints.”

The most important part of any of these plans is to make sure that the patient is prepared for the experience. “We try to always tell our patients we know they have been waiting for some time,” Gail emphasizes, “and we could probably see you much sooner if you are okay with being seen by a PA in the hallway, and to let them know that they will also be seen by a physician before they are discharged.” Gail adds, “We are also careful to emphasize to our patients that if they choose not to be seen in a hallway bed, that is perfectly acceptable. However we are up front with them that it will in all likelihood take them longer to be seen.” Gail says that they have found that “treat and street” helps to keep patients flowing and has resulted in decreased bottlenecks at the 7 p.m. change of shift time.

“These plans really do work well,” Gail adds. She says that they occasionally get a comment about a patient having to be seen “in the hallway,” but overall patients like being seen and taken care of quickly. The PA always tries to remember to apologize to patients for the lack of a room in which to see them. But again, it’s important to prepare the patient for this “quicker” service.

Bottom line, our emergency department has demonstrated reduction in turnaround time since the implementation of these plans. During October, they cared for a record number of patients for a single month and for the first time saw over 200 patients on five separate days. Overall, through conscientious use of these processes, the average length of stay for all patients has been reduced by 10 minutes.

“We’ve looked at best practices and that’s why we have these plans in place,” Gail emphasizes. “We work hard at ‘capturing the moment’, not just using the same routine – we use everything we have RIGHT NOW, in order to move our patients through the system more quickly.”

This department has sustained their 60-minute pledge for admitted patients for over 5 1/2 years, that is, 80 percent of patients admitted through the ED are transferred to their inpatient bed within 60 minutes of the time the physician provides admission orders. Gail is quick to give credit to the inpatient units for making this happen. “Our inpatient staff realizes our patients want to be in their bed as soon as possible,” she says. “For the remaining 20 percent who do not attain that goal, most often there is a valid reason for the delay, such as the completion of additional tests or treatment.”

“Customer service is always at the core of what we do,” Gail emphasizes, “and Linda Cover, our customer service star, is so good at keeping people informed, taking care of their needs, and communicating to family and friends who are waiting for information.” Gail adds, “But our first issue is that we are doing our job, that clinical aspects are evaluated and taken care of.”

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