Patient Flow E-Newsletter
Volume 3, Issue 4
Thursday, December 21, 2006

Innovations
Going Electronic in the Emergency Department: Why Every ED Physician at Parkview Medical Center Now Has a PAL

Several years ago, Parkview Medical Center in Pueblo, CO began to explore a hospital-wide electronic medical record (EMR) system. Hospital leaders believed it could increase patient safety by reducing illegibility and simplifying the coding and billing processes. Their hope was that the EMRs would significantly hasten the turn-around time for patient records, as physician dictation often took several days to come back in electronic form.

With 32-beds and more than 50,000 visits a year, Parkview's emergency department (ED) volume was increasing by close to double-digit percentages annually. Hospital administrators thought the ED would be a good test case before implementing an EMR system hospital-wide.

Early in 2004 the ED went high-tech, with mobile laptops and desktop computers set up throughout. Using the MEDITECH system, they believed paper files would disappear. Lab work, radiology results, x-rays, medication histories, and more could simply be pulled up on the computer screen.

The EMR system's implementation had taken almost a year, but when it was complete, Parkview administrators, physicians, nurses and staff alike realized that it was not an all-around success.

"Doctors and nurses stopped talking with patients," said Mike Archuleta, Director of Emergency Services, Parkview Medical Center. "Of course, they were talking to patients, but they weren't looking at them. Instead of engaging with their patients, they were just talking to the computer screens."

Patients took notice. Satisfaction surveys started coming back with lower scores, and this wasn't the only drawback. After going electronic, average ED wait times surprisingly increased, because doctors could dictate after-care instructions, prescription orders, etc. more quickly than they could enter the data electronically.

Because doctors were spending more time with each patient, the ED's length-of-stay numbers increased. More alarming, the left-without-being-seen (LWOBS) rate increased to 2.5 percent. Previously, Parkview's ED had prided itself on LWOBS rates that were below the national average of 2 to 5 percent.

"When your statistics and performance measures change for the worse, you're tempted to put the new technology on the shelf and go back to the way things were," said Archuleta. "We fought that urge and looked for ways to eliminate the drawbacks without throwing out the system."

Archuleta's proposed solution was to pair each emergency physician with a Physician Assistant Liaison, or PAL, on every shift. The PAL would accompany the physician every time he or she interacted with a patient, entering the data electronically for the physician.

Like any new idea radically different from the norm, the PAL Program was met with some initial skepticism. While Parkview's ED medical director and Parkview's chief nursing officer were cautiously supportive, they wanted the program to be piloted before taking it ED-wide to ensure compliance with HIPAA regulations. Some of the physicians were very skeptical as well.

"During the pilot phase, we tried having emergency medical technicians and paramedics fill the PAL role," said Archuleta. "However, we quickly realized that they didn't have enough Pharmacology or Anatomy in their background, and they were not familiar with all of the medical terminology. A doctor would name a medication, and they often didn't know what it was."

Consequently, eyes turned to the hospital's established nurse intern programs, run in conjunction with Colorado State University-Pueblo and Pueblo Community College. Archuleta and the team he assembled (including the ER nursing director and medical director, a registered nurse, an emergency medical technician and paramedics) taught the ED's electronic system to the second- and third-year nursing school interns, who then began working with physicians to complete bedside order entry, from blood counts to prescriptions to chest x-rays.

This time it worked. Doctors had enough time to explain things thoroughly to patients and their family members, and the nursing intern PALs had the knowledge to act as scribes by quickly and efficiently entering all of the data electronically. Working as a team for the duration of the shift, the two would work hand-in-hand in interactions with every patient.

PAL job description

"Now there are some ED physicians from whom I couldn't possibly take the PAL system away," said Archuleta. "Some of our newer ED physicians have never worked without a PAL. I think they would really miss it if they left Parkview."

The PAL program is also paying off in ED performance measures. On average, ED patients are being seen 15 minutes faster than they were before the program was introduced, and length of stay has crept back down to numbers seen previous to EMR implementation. Throughput has dramatically improved, with physicians seeing .5 patients per hour increasing to an average of 2.5 patients per hour since PAL was put into place with nursing interns.

PAL brought several additional, unexpected benefits including:

As in many institutions, there had always been some division between emergency nurses and physicians at Parkview. Luckily, the PAL program has helped close that gap. ED physicians now have a vested interest in the nursing intern PALs. For the first time ever, they are helping to train future ED nurses. In turn, the PALs get to know the work style, practices and preferences of each ED physician, often becoming so familiar with their partner physicians that they go ahead and initiate the appropriate protocol.

Many of the PALs have gone on to be hired as ED nurses at Parkview, and according to Archuleta, hardly need the training and orientation typically provided to newly hired nurses. The hospital's emergency physicians have found that the PALs who are eventually hired are often a step ahead of more experienced nurses who join Parkview from other hospitals.

Archuleta thinks the benefits go both ways. Since the program was instituted, every Parkview nursing PAL has passed the state boards. Working hand-in-hand with the emergency physicians helps them learn to quickly assess patients. Some of the hospital's experienced ED nurses have even grown a little envious of the knowledge the PALs are gleaning by working so closely with individual physicians, so several have requested to spend some time in the PAL program themselves.