Patient Flow Enewsletter
Volume 1, Issue 8
Tuesday, November 16, 2004

Best Practices
Creating an Award-Winning ED

Resources in this article: Flow chart of an improved triage process Nursing Process Council to improve patient flow Flow chart of an improved Direct Admit Process

 
When Susan Key, RN, MS, CEN was hired as director of emergency services at Cape Canaveral Hospital in Cocoa Beach, Florida, she was only given one task: to make Cape Canaveral Hospital's emergency department (ED) one of the best in the country. Faced with soaring patient volume, significant overcrowding, low patient satisfaction, and low staff morale, this was no simple task. Left with little else, Key utilized her 18 years of experience, a patient-focused philosophy, and an extraordinary amount of drive and determination to accomplish the task.

Identifying Barriers to ED Efficiency

Taking a step-wise approach to this challenge, Key first worked with ED management and physicians to identify some of the barriers that were keeping the ED from running at an optimal level and then implemented some changes.

Other barriers identified by Key and her team included fluctuations in patient volume; inflexible staffing mechanisms to compensate for volume increases, and delays in discharging and admitting ED patients. "ED patients could be waiting up to 6 hours, which may be ok with some ED nurses, but it wasn't ok with me," said Key.

Key and her team developed and implemented several strategies that would have a direct impact on improving ED efficiency. For example, the triage and registration process was simplified so the patient is immediately received upon entering the ED, triaged, and then taken to a treatment room for bedside registration. Once these strategies were implemented, average patient wait times fell from 90 to 15 minutes in just six months.

See a flow chart of improved triage process.

Addressing Patient Flow

Key also established a Nursing Process Council (NPC) to look at patient flow through the facility. The NPC was charged with establishing collaborative methods to identify and resolve issues related to patient flow and to empower staff to make decisions about worksite issues that impact patient care. Membership in this council included representatives of nursing; radiology; respiratory therapy; registration; environmental services, and other departments on an ad-hoc basis depending on the problem or issue encountered by the team.

By taking a "let's look at what is best for the patient" point-of-view, the NPC identified several issues and problems in the acute care setting that could be addressed to improve ED patient flow. Together, they selected the Admission, Discharge and Transfer (ADT) process as a priority project because of its significant impact on patient care.

See a sample of the improvement process.

"What we found with the ADT process was that there were nine different ways physicians could get their patient admitted to the hospital. This was causing two major problems: first, physicians were often sending their non-urgent patients to the hospital for admission. And second, physicians weren't using a consistent system in admitting patients to hospital floors, so there was no way to determine and prioritize which patients should get beds. Therefore, there was often little bed space left for urgent patients from the ED," explained Key. "Our goal was to streamline the admission process to improve productivity, efficiency, and patient and staff satisfaction."

By streamlining the ADT process, the multiple points of entry physicians were using to admit patients were eliminated. This decreased ED holding time since there was a global patient admission system to prioritize patient beds. It also allowed appropriate resource allocation on weekends and holidays in all areas that affect patient care, insuring no beds are left empty due to staffing shortages. It also improved the housekeeping process, which facilitated bed turnover.

See a flow chart of the streamlined Direct Admit Process.

Earning Staff Buy-In

Key said having the support and buy-in from senior hospital leadership and staff was essential to making the new ADT process work. "Communication and education is the key to getting staff and administration buy-in," she said. "You need to encourage staff participation in solving problems and making decisions and solicit feedback from staff and administration as you go."

Once the new ADT process was developed, Key and her staff worked hard to educate medical staff to secure their full support. "We did a lot of teaching right in physicians' offices to educate them on the new process and to garner their support," she said. "It took about six weeks of office visits. Then once we were done educating them, we gave them a drop-dead date for feedback and then initiated the new process."

Key says that one of the factors for their success was creating a positive environment that was conducive to team work. "Establishing an environment of trust is critical," she said. "While having a strong leader is important, the leader must embrace different thoughts and always try to collaborate if everyone is going to share responsibility for fixing the problems and determining the solutions."

Key also recommends listening to those who are in the trenches and says, "those who are at the bed side really know what's going on. Be sure to work with them and assure them that they are being listened to." She adds that, "creating a common vision really motivated the team - we all worked together to be the best ED in the country."

For more information about Cape Canaveral's approach, Click Here to download Susan Key's full presentation, "How to Create an Award -Winning ED When You Are Overcrowded, Overworked and Overwhelmed". (3.3 MB)

To listen to an audio recording of Susan Key's presentation from the November 11-12, 2004 conference titled "Perfecting Patient Flow: Proven Solutions to ED Crowding," Click here for more information.

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Susan Key, RN, MS, CEN
Director, Emergency Services
Cape Canaveral Hospital
Cocoa Beach, FL