Help with decreasing ED wait times ...

[RNSurf]

We are focusing on trying to move patients back to rooms faster and decrease wait times. Our current system consists of having a patient walk in and fill out a card with name, birthdate, and chief complaint. Our Triage nurse registers the patient in the computer system and then calls the patient back to do vital signs plus a computer history questionaire including current medications. This takes approximately 10 minutes per patient on average. If a room is available and time permits the patient is taken straight back however all too often we end up with a bottleneck of patients waiting in the lobby when more than 3 patients show up at a time because it's at least 20 minutes before the 3rd one is initially seen by the Triage nurse. Adding staff is not an option so pulling a nurse from the back would mean less rooms available. One idea was to have patient complete a written history questionaire while waiting similar to forms handed out while waiting in a physician's office. Another idea was to have the Triage nurse do a "mini" by inputting vital signs and chief complaint only ... then have the primary nurse complete all other information such as weight, medical hx., PCP, allergies, meds, etc. Perhaps she could do this off the written form given to the patient but I have to wonder if that would just transfer the bottleneck back to the rooms. Of course it doesn't make it any better that one hospital in our state of Florida now advertises ED wait times on an electronic billboard located on the interstate. Last time I drove to Miami it was flashing 14 minutes. Any suggestions would be appreciated as I'm sure we all face the same challenges. Our ED sees approximately 100 patients per day and starts with a CCN, 4 floor nurses accomodating 16 patients total, a Triage nurse, a secretary, and two ED techs who perform EKG's, wound care, ortho, and assist with procedures. We add one nurse at 11am and two at 3 pm. We currently do not staff with medics or phlebotomists so perform all IV starts.

[WonderRN]

at our ED, we have one nurse that does vitals, allergies, and primary complaint only, then assigns acuity. Takes 5 min or less. If there is an open room, they go right back. If not, they go to the second triage nurse, or if the second triage nurse is busy, they go back to the WR, to be called back by the second triage nurse when she is available.

She gets an extended complaint (as necessary), medical history from the patient, fall risk, and enters protocol orders. If the triage tech is available, they do the protocols then.

If there is a back log for the 1st triage nurse, the patients wait in a line at the desk (don't really like that part)

Seems to work pretty well. The theory is the first triage nurse can get a "gut" feeling how sick the patient is during that primary triage. Medical history can wait, unless it pertains to the immediate situation (fall on coumadin, etc).

Home meds are always put in by the pt's nurse when they get back in the room

Now this triage system only operates 11a-11p. After 11p, we have one triage nurse that does just primary triage. She will call the waiting patients back up when she gets time to do their secondary, and enter protocol orders. We are working on trying to get 2 triage nurses at all times.

We see normally 120-140 patients per day. We have 5 nurses for 20 "regular rooms", and 2 nurses for up to 10 "fast track" beds, plus one charge nurse. And on a good day we have a circulating nurse at any given time. (in addition to the 1-2 triage nurses) Usually 3 techs for the care areas and 1 out at triage (they are looking to add another circulating nurse, more techs, and few sitters)

Of course there are kinks in the system. It puts more work on the nurses in the care areas as they have to do more work with the meds and history if its not done out front. And it never fails that you have to amend the history once you get a look at their meds. And it DOES bottleneck the rooms at times, which is frustrating, because you can get slammed all at once with a bunch of patients/ stuff to do. But, its all about the almighty press-ganey, and patients perceive a room is much better than the waiting room.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

Can't help with the patient flow. You've got a fixed amount of work to be divided by a fixed number of staff. Unless a "fixed" can be changed to a variable, there's not a whole lot you can improve overall.

On advertising waiting times, though, if you thought you or a loved one was having a true emergency, would you want to go wait 14 mintes? Long ago I adopted a firm answer to the question of waiting times; life threatening emergencies are seen immediately, all others follow in order of severity. Hope this helps a little.

[nurse2033, MSN, RN]

Without the option to reassign staff not sure. Our greeter is an EMT who takes the pt info and enters them and does VS. The triage RN can eyeball everyone coming in, but usually waits until the pt is registered. This can be done quickly. The triage RN then "triages" the patients based on complaint, presentation, and VS if they start to stack up. They then call the patients in in the order they deem best. This system works pretty well because the RN is free to treat any patient that needs urgent care while the EMT is still available to enter new patients and the desk is covered. Hope this helps.

[Rickbos]

Somehow the emphasis with ER care has been put on giving the patient the "false sense" that they are getting treated better by rushing them back in to a room in the shortest amount of time regardless of their acuity. It is an attempt to increase Press-Ganey scores and in my opinion, this flies in the face of "real" triage.

If a patient is triaged properly, they will get back to a room immediately if they need it, if not, they will go to the waiting room and go to a room when it is available and the ER staff in the back deems it "safe" to bring them back, not just because a room is available. This concept of "immediate bedding" seems to defeat the purpose of triage.

If you fill up all the rooms on a "first come first serve" basis, regardless of acuity, what happens when you need a room for an emergent patient? Valuable nursing time is wasted moving a patient that could have been in the WR out, so you can move the sick patient in. Triage was designed for a purpose and we seem to be ignoring that purpose to get better PR.

[Altra, BSN, RN]

Long ago I adopted a firm answer to the question of waiting times; life threatening emergencies are seen immediately, all others follow in order of severity.

Amen. I also firmly adhere to a personal policy of never estimating wait time, because truly, at the same time some magic number is coming out my mouth, things can change based on the next person that comes in the door.

The best setup I have seen is where patients came in the door in full view of the triage nurse, so that they could be eyeballed even while another patient was being triaged, but "greeted" by registration staff who immediately entered name, DOB and chief complaint into the tracking board. The charge nurse continually monitored the tracking board, so that as soon as a CC of, say, chest pain popped up, that patient was pulled back immediately, moving another patient out to a hallway bed if necessary. For the most part, potentially emergent chief complaints like chest pain or CVA symptoms were never triaged out front, but siphoned out of the flow and immediately put in rooms so their workup could begin. Every effort was made to staff the urgent care portion of the ER adequately so that ESI 4 & 5 complaints were also pulled back to urgent care by the nurses & medics staffing those rooms, again to get them out of the flow of patients requiring triage out front. The triage RNs then triaged by acuity of chief complaint or based on their eyeball assessment of anyone who looked toxic disproportionate to their stated chief complaint.

[EmergencyNrse]

.... announce to the waiting room that you are out of Dilaudid and turkey sandwiches.

[ImThatGuy, BSN, RN]

Buy newspaper space with catchy lines telling people not to come to the ED unless it's a real E.

[JD228]

It sounds like the size of our ER is comparable. We have a tech and RN at triage. The tech gets the info and does a quick register in the computer and the RN can ask the chief complaint, allergies and a short history of events. Tech does VS and takes the pt to the room or releases to waiting room if no bed available. We work on the 5 level acuity system and have the level 4 and 5- lower acuity patients go to one area and the level 1,2,3 to the other rooms.

It really helped us that we developed a rapid triage form that the top section was sign in information i.e. name, dob, ssn, physician, lmp....etc. So you can allow the patient or family to fill this out if you are backed up and then the triage sheet is below that- you fill in a few key info pieces. The primary care nurse is required to ask the past medical history and medication list. The thought here is that your primary care nurse needs to know the meds and past medical history and wasn't always reviewing that info on the chart before caring for the patient- so it forced the nurses to acknowledge that info.

It also helps that we have 2 security monitors so we can see what is going on in triage from the back- most of the staff is really good about going out front and getting peopl to bring to available beds, esp when backed up.

Hope that helps!

[LUStuRN]

We recently started a new process improvement in our ER. We eliminated the waiting room. No patient ever waits. The patient walks in the main doors, is quick registered. A tech (paramedic) vitals the patient, obtains chief complaint, and brings the patient to the back. The charge nurse quick assesses the patient and directs the patient where to go. We have 3 zones, red green and yellow. Red zone is critical patients. Yellow and green are considered fast track patients, or any patient who can sit in a chair. If you want more information, message me. Since starting we have not had to open our waiting room, not one patient has waited to go to a room. We have not been on bypass, we have only had 2 patient leave without being seen in 2 months. Prior to starting we were on bypass 3-4 times a week, had >200 LWBS patients per month.... Amazing redesign, works very well.

[Altra, BSN, RN]

We recently started a new process improvement in our ER. We eliminated the waiting room. No patient ever waits. The patient walks in the main doors, is quick registered. A tech (paramedic) vitals the patient, obtains chief complaint, and brings the patient to the back. The charge nurse quick assesses the patient and directs the patient where to go. We have 3 zones, red green and yellow. Red zone is critical patients. Yellow and green are considered fast track patients, or any patient who can sit in a chair. If you want more information, message me. Since starting we have not had to open our waiting room, not one patient has waited to go to a room. We have not been on bypass, we have only had 2 patient leave without being seen in 2 months. Prior to starting we were on bypass 3-4 times a week, had >200 LWBS patients per month.... Amazing redesign, works very well.

OK, I'll bite.

Whether you have 5 beds or 50 beds ... when all those plus all available hall spaces fill up ... how is there no waiting?

The charge nurse "quick assessment" -- does this include any hands on assessment (auscultation, palpation, etc.)? If so, where in the ER is this done with any privacy and/or how is this done effectively with the patient still dressed? Or is this "quick assessment" really just taking a history?

Does the charge nurse have other responsibilities regarding patient flow, serving as a resource, etc?

Where do patients waiting to be quick assessed by the charge nurse wait?

[RNSurf]

Yes, I'd really like to hear more details about the flow ... thanks!