Efficiency in the emergency department is vital, not only because EDs often face large patient volumes with many requiring immediate medical attention, but also because it is the front door to your hospital — often the first, and in some cases, the only place where a patient experiences care in your facility.
During a Nov. 27 webinar sponsored by Philips and hosted by Becker's Hospital Review, Cheryl Hoey, BSN, RN, and Karen Webb, MSN, RN, discussed the steps that Hartford-based Connecticut Children's Medical Center took to improve operational efficiency in its ED. Ms. Hoey is senior vice president of clinical services and chief nursing officer at Connecticut Children's, and Ms. Webb is a senior consultant at Philips Blue Jay Consulting, who stepped in as interim ED manager at Connecticut Children's.
Connecticut Children's Medical Center is a freestanding 187-bed pediatric hospital. It's ED includes 38 beds and sees an average of 61,000 annual patient visits. Three to four years ago, the medical center started looking more closely at its ED operations, noting that volume was increasing, wait times were up and patient experience was not where they wanted it to be, said Ms. Hoey. Additionally, a patient safety event galvanized the leadership team to look at additional resources and expertise to improve ED processes.
"We really wanted to create something sustainable, something consistent, something that we could count on carrying us into the future," Ms. Hoey said. "We definitely needed assistance with that."
And that is where Philips Blue Jay Consulting came in. They provided Karen Webb as an onsite consultant who provided interim leadership to help with day-to-day ED management as well as an assessment of operations and implementation of new processes.
Philips looked at helping the medical center improve operations in certain areas within the ED, said Ms. Webb. Here is a snapshot of the improvements made:
1. Front-end processes. Connecticut Children's used Lean principles as well as process mapping to root out inefficiencies. Among the many barriers to front-end efficiency in the ED was a long registration process for visitors. According to Ms. Webb, the process could be particularly challenging in cases with sick children and full families in tow. So, Connecticut Children's implemented a quicker registration process by moving certain elements of registration typically completed on the front-end of the process to the back-end.
Connecticut Children's also implemented a direct bedding process, which involved the creation of two different pathways to get patients into a room and a bed as soon as possible so they could meet with a provider. One pathway was designed to be implemented when beds were available, and another when beds weren't available, both accounting for the varying volumes at different times of the day. The hospital also discovered that technician support was key for getting patients into beds quickly.
2. Triage. One of the biggest changes Connecticut Children's made in terms of triage protocols was aligning them more closely with Emergency Services Index (ESI) guidelines. While the hospital had already adopted ESI guidelines for triage, a closer examination of the processes suggested it was necessary to re-train staff and increase the number of trained staff members. Ms. Webb said they tested the entire team and tapped high-performing staff members to help educate the others. They also used charge nurses to help monitor triage and provide coaching.
Additionally, the medical center revised triage templates in its Epic EHR to match the flow they had in mind as well as made sure there was a dedicated RN in triage 24/7.
3. Charge nurse development. The medical center created a charge nurse core group, outlined expectations for these nurses and created a customized training curriculum for them. This group began to meet with clinical leadership on a regular basis, review and agree to change initiatives as well as hold each other accountable for supporting these efforts.
"Charge nurses were really crucial and key to all of the successes that we saw," Ms. Webb said. "As soon as they identified and understood what we were striving for, they really embraced it and helped support the processes."
4. Handoffs and daily huddles. The medical center implemented a shared handoff and made changes to who would be leading the shift change. Previously, the nurse manager going off the shift had led the handoff, but they found that sometimes if the nurse manager had experienced a rough shift, "the nurse was not able to rally the troops and be positive," Ms. Webb said. Connecticut Children's changed it so that the oncoming nurse manager would lead the shift huddle, and this helped the team look to the next shift with more clarity.
The medical center also established daily huddles involving the nursing team as well as physician partners and residents. The expectation was that if you could, you were expected to attend the daily huddle, said Ms. Webb.
5. Patient experience. A patient's experience in the ED can make or break their opinion of the facility overall. Connecticut Children's made several changes to improve patient experience, including establishing bedside suture carts so physicians didn't have to waste time finding the equipment and could instead quickly use the carts, allowing for quicker patient discharge.
Ms. Webb said Connecticut Children's also set expectations with the leadership team about rounding and offered benefits for families staying in the ED, such as meal passes and toothbrushes and toothpaste.
6. Minor care area. When the medical center's ED volume spiked and its rate of patients leaving without being seen increased, Connecticut Children's pulled together stakeholders from the entire organization to address the issue. They created a minor care area that served as an alternate site of care and added 11 patient rooms. Pharmacy, materials management and other departments brought together all that was needed to establish the minor care area in seven days.
"It was a great demonstration of a collaborative effort and understanding flex spaces to meet the needs of patients," Ms. Webb said.
Results
Due to improvements made in ED operational efficiency, Connecticut Children's reduced arrival-to-triage time by 80.5 percent — from 10.99 minutes to 2.14 minutes. It also reduced left-without-being-seen rates by 55.8 percent, gaining $380,000-plus in additional collectible revenue annually.
These achievements resulted in Connecticut Children's winning a Lantern award. The prestigious award is given by the Emergency Nurses Association and is akin to Magnet recognition but specific to EDs.
To learn more about Philips Blue Jay Consulting, click here, and view the full webinar here.