Ideas for improving flow...

[Anna Flaxis]

Sorry if this has been discussed before, but I'm looking for ideas on improving the flow in a small community ER during really busy times.

We are a small, 7 bed ER with no charge nurse, and we practice team nursing, so when things get busy, things can get chaotic and it can be difficult to get everyone on the same page. It's easy for care to be duplicated, and it seems each nurse has their own ideas about how best to flow the patients through. During peak hours we have three nurses for 7 beds, which is a fantastic ratio, but still things get bogged down and the only reason I can think of is that we are disorganized.

My thoughts are that during peak flow times, we need to assign roles and rooms. One nurse takes the 2 trauma bays plus one regular room. The second nurse takes two regular rooms. The third nurse functions as triage and runs a fast track for low acuity patients in the ENT, hallway, and last regular bed.

I'm trying to think of the drawbacks to this plan and anticipate the resistance I'm sure I'll get to my proposal, and also some links to research on the topic would be appreciated. I am an ENA member and I have scoured the website to no avail. Also, I have attempted in the moment to bring some organization to the chaos and formulate a strategy, but it's hit and miss as far as getting buy in from my coworkers. Some are open to it, and for others it just goes in one ear and out the other. But it is clear to me that we need a plan, and I'd appreciate any thoughts or ideas on the topic.

[applesxoranges, BSN, RN]

What do you mean cpr in progress has to go to the cath lab?

It sounds like there may be a facility nearby that staffs a cath lab or has a team on call. My old hospital we had a hospital within 1 mile of us. Different competitors.

[canoehead, BSN, RN]

I worked in a 7 bed ER with a similar staffing pattern. And we didn't have patient assignments. But it wasn't as confusing as what you describe. If you pick up a chart to do orders, take the chart with you so you can document and no one else starts working on it too. Pull until full didn't work for us for lower acuities, people get frustrated, they expect to be seen once they are in a room. And filling all your beds leaves you with no where to put the really sick that show up.

We had an informal assignment- whoever brought the patient in owned them. Others would help out, and sometimes two nurses would be needed to stabilize, then the least busy person would take over. We'd always try to have a room open for ambulances.

At night one nurse would be there, with a secretary if you were lucky. We could ask the maintenance guy to come direct traffic and answer phones, or call the med surg unit and beg for mercy. We'd be their backup for a crisis too, so it worked out. On paper we were able to call EHS to help do tasks, but in real life it didn't work out. Sometimes they'd be pretty unwilling to be pulled into more work, or they'd be the ones out on a call bringing in all the work.

[Gabby-RN]

It sounds like there may be a facility nearby that staffs a cath lab or has a team on call. My old hospital we had a hospital within 1 mile of us. Different competitors.

I just meant that every cardiac arrest doesn't go to the cath lab, at least not where I work.

[Anna Flaxis, BSN, RN]

No, not every cardiac arrest needs to go to the cath lab, but a frequent cause of V-Fib arrest is AMI, and those patients need emergent PCI. Why bring a cardiac arrest to a small community hospital who's ICU might not even be staffed, when there is a big regional medical center with a cath lab and a staffed ICU right up the road? Again, the only reason would be if the paramedics cannot get an airway and we're the closest. Does that clarify?

[TLSpaz, ASN, RN]

5 Best Practices for Improving the Throughput of the Emergency Department

[jguiney]

I run a 12 bed ED, From 11-2300 my busy time I have 4 I have a charge/triage, who takes fast tracks, I have 1 nurse who takes my 4 patients rooms mid acuity. I have one who takes 3 high acuity rooms, and one who takes 4 fast track and lower acuity. It is a team but they have assignments. I have just received approval of a 5th nurse from 1500-0100, she will become a piviot/charge in the back and then leave a dedicated triage. We fill till full. We see over 16,000 a year avg. 44-50 per day.

From 2300 -0700 there are only 2 nurses with a house supervisor to pull from.

[thelema13]

We are switching to a 'pull til full' model in a few weeks. We have done this before with bad results, mainly because our ED hires new grads and most of the charge nurses remain stagnant in their chair. Pull til full only works if you have great flow control, that is, supervisors willing to give beds ASAP, doctors willing to sit down for 15 minutes and dispo as many as possible, etc. Our ED was remodeled and now holds 32 beds plus hallways, and the managers got us a mid-level and are proposing 2 charge nurses, taking away the triage nurse, having a full time float nurse, yada yada.

Our mid-levels are not allowed to see peds under 1 year old, and they have to be a level 4 or 5. They are underutilized to say the least.

The ED works as it is, and it is my mantra that 'if its not broken, dont try to fix it.'

Someone in corporate that has their Master's degree that has never held a nursing job is trying to implement change and test a hypothesis. No other way to put 6+ years of school to work!

Sounds like if you do not have a charge, why not designate a team leader? 3 nurses for 7 beds is awesome, you guys have enough manpower but how is patient flow? Do you have a medic or tech? And I think a room assignment would be awesome, split the room 3/3/1 and whoever has the 1 trauma room will be the float/charge. Walkie talkies for staff for easier communication?

[exit96]

I believe in the Charge Nurse role. I work a small rural ED, and we have at least 1 real good Triage Nurse. But even that individual can get caught up in emotions, and a level headed, QUALIFIED, charge Nurse would be a good balance....

[Anna Flaxis, BSN, RN]

I believe in the Charge Nurse role. I work a small rural ED, and we have at least 1 real good Triage Nurse. But even that individual can get caught up in emotions, and a level headed, QUALIFIED, charge Nurse would be a good balance....

I agree with this. It makes such a huge difference when working with someone who can see the big picture, remain calm and composed, and make appropriate decisions regarding flow. I think one of the issues here is.... here it comes....*changing the way we've always done things*. I don't think it's as hard to think of better ways of doing things as it is to get buy-in and actually implement new processes.

This thread is really helpful. Keep it coming!

[delphine22]

I think one of the issues here is.... here it comes....*changing the way we've always done things*.

Maybe you'll be lucky and there will be one person who always wants to be charge -- or maybe everyone wants a turn. Hopefully you find a solution where everyone is (mostly) happy.