Flow improvement

Specialties Emergency

Published

Specializes in ER.

I'm working with a multi-disciplinary committee that includes both department members and several other hospital-wide members to identify barriers to efficient patient care and flow both within the ED and transitioning to the inpatient side. Constraints--- add no FTE's, and we will not be considering any major construction. This project will be several months in duration and is only in the beginning stages.

I'm reaching out to this forum because I think you may have valuable ideas and experiences. I'm curious as to what issues you've encountered in your departments in terms of flow, and what has been done to resolve them. We are identifying time wasting activities/processes in order to better serve our patients. We are a large ED, appx 90 beds, seeing 100K patients/year. We use a bedside triage model when possible, and have 3 acute "pods" a fast track/minor acute area, all with their own providers/PAC's. 2 radiology areas, 3 CT scanners, and several US techs on at any given time. We are also a trauma center, with a large population of elderly falls with anticoagulants.

What time wasters do you have your department...and has anything been done about it?

Thanks for your input!!

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Specializes in Emergency.

What's your average TAT from door to floor bed? To really break it down and find the time wastes, you'll need to do a Lean analysis. That's either in house six-sigma staff and/or consultants and it costs.

Good luck.

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Specializes in ER.

We have in house consultants on the project. I do not know exactly what the TAT is, but am hoping to find out tomorrow at our meeting.

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Specializes in Emergency.

Turn around time. Includes door to doc, time to test, decision to admit/dc, admit order placed among other things.

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Specializes in ER.

I should have been more clear. I know what TAT is...I just don't know our values. ;)

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Your department has similar size and structure to where I work.

The area we are most deficient in is transport staff. Patients usually wait 30-60 minutes on transport board to move up to the units. We also do not have transporters dedicated to bringing patients to CT which causes delays. It is a hospital policy that an RN must accompany the patient on transport for all patients admitted with a cardiac monitor. About 75% of admits are monitored.

Another thing that causes delays is that our radiology department wants oral contrast for all abdominal CT's-adds 3 hours minimum to the disposition.

We are a teaching facility, dispo's tend to be slow in general. We also tend to admit everyone with CP for ACS rule-out. There never seems to be enough inpatient beds and we always have boarders.

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Specializes in Emergency.
Your department has similar size and structure to where I work.

The area we are most deficient in is transport staff. Patients usually wait 30-60 minutes on transport board to move up to the units. We also do not have transporters dedicated to bringing patients to CT which causes delays. It is a hospital policy that an RN must accompany the patient on transport for all patients admitted with a cardiac monitor. About 75% of admits are monitored.

Another thing that causes delays is that our radiology department wants oral contrast for all abdominal CT's-adds 3 hours minimum to the disposition.

We are a teaching facility, dispo's tend to be slow in general. We also tend to admit everyone with CP for ACS rule-out. There never seems to be enough inpatient beds and we always have boarders.

Yes, transport is a huge issue. Even though these initiatives are supposed to be budget neutral, the only way to fix a lack of transport is to hire more transporters. Not a huge expense and while it's tough to sell, it can be done.

We have the same policy about transporting tele pts so we always ask for "transport without tele" order unless they're going to the unit, do actually need nurse/monitor or have a titratable drip. Usually get the order.

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Yes, transport is a huge issue. Even though these initiatives are supposed to be budget neutral, the only way to fix a lack of transport is to hire more transporters. Not a huge expense and while it's tough to sell, it can be done.

We have the same policy about transporting tele pts so we always ask for "transport without tele" order unless they're going to the unit, do actually need nurse/monitor or have a titratable drip. Usually get the order.

I wish we could request orders to transport without tele. I understand the need to transport an unstable patient on tele but an ACS rule out that has not had any CP the entire time in the ED with an initial negative troponin, a patient with known afib with a rate of 88, or a patient with respiratory complaints that most likely has CHF exacerbation or asthma that is resting comfortably and talking full sentences on their phone? Requiring a nurse to go on transport is a waste of resources.

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Specializes in Emergency.
I wish we could request orders to transport without tele. I understand the need to transport an unstable patient on tele but an ACS rule out that has not had any CP the entire time in the ED with an initial negative troponin, a patient with known afib with a rate of 88, or a patient with respiratory complaints that most likely has CHF exacerbation or asthma that is resting comfortably and talking full sentences on their phone? Requiring a nurse to go on transport is a waste of resources.

If I was so slammed that I didn't have the time to do that transport, I'd call my house supervisor and tell them to find someone to transport the pt or to come down and take over my other patients while I did it. I've only had to do it once or twice, but It's gotten results. Of course, I'm in a much smaller facility with no charge nurses, so your mileage may vary... :)

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Perhaps it's time to push for the change where you all don't have to have nurses go with tele patients. Our nurses only go with ICU/PCU or patients on cardiac drips to the floor. It's our policy. If you feel a new policy would be better suited for times and is safe, then I'd say you need to really push for that. There is no reason to use up resources when it's not actually needed.

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Specializes in ER.

I don't think there is a lot of time wasted in our department transporting patients to hard tele areas. We do have medics available much of the time for those transports. An RN must accompany a patient receiving blood products, or any patient going to an ICU (not step-down). We do wait for standard transport frequently, and for a variety of reasons (staffing, volume, etc). This can delay the patient leaving the department by 60+ minutes at times.

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Specializes in EMERGENCY - TRAUMA.

I have worked at large and small hospitals and everything in between and while it varies in severity a few constants seems to run through all the facilities. For starters beds being released after an admit order gets put in. Sometimes, it has taken several hours to release a bed. Various excuses from it's not clean, to we have to move a pt out of that room to name a couple have been given. Another issue is, again it varies, is trying to get report called to the floor. I do not have time to remain on terminal hold, and it's been my personal experience having the nurse call me back is dicey at best. Finally, admit orders heavy with "now" orders. Yes, sometimes they are warranted but not in the excess I have experienced. Oh, one final thing. Holding an admit pt in the ER so an admitting doctor can come see them before transporting to the room. Seriously? Walk the extra 100ft to the elevator and go see the pt upstairs.:sour:

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