How Does Your ED Flow? Need Suggestions

[All4NursingRN]

So I'm about 5 months into my second ED job and let me say the grass is NOT always greener. Life lesson learned lol. But I still want to make the best of it and would like to find ways to contribute to hopefully making the dept better. To be blunt this ED's structure is non-existent at best and dangerously chaotic at worst.

Some facts are:

-Small to Medium size High acuity Level 2 ED

-60,000 annual visits with spiking numbers due to nearby hospital closure which is dramatically less visits than the 120,000/yr visit ED I came from but it seems busier because it is less organized and much smaller in size.

-Under-served/safety net hospital mostly serving the medicare/medicaid, uninsured and poor.

-2-3 triage nurses (1 ambulance/2 walk in or 1 walk-in and 1 screener nurse) depending on staffing (smh) and all 2 or 3 nurses will assign patients simultaneously often leading to dumping a nurse with 2 patient at once or back to back.

- Admission back-log. I'm not sure of the hard numbers but nearly all patient spend at least 12 hours minimum in the ED after being admitted with no inpatient bed.

I can go on and on. Here I don't feel the standard of care or patient safety is adequately being addressed despite administrations repeated meeting with us that things are ''going to get better, we promise'' meetings have dwindled and morale is sinking.

I'd love to find a way to work with administration and explain that standards of nursing need to be elevated and standards of care should be improved without being negative.

So perhaps I can stir some discussion on what works best with your ED, what has worked and what hasn't, particularly in inner city, high acuity/volume departments.

How to you manage/foster nurse to doctor communication?

Managing high acuity patients safely?

Standards of nursing documentation?

Increasing working knowledge and requirements of acute conditions?

TIA!

[AnnieOaklyRN, BSN, RN, EMT-P]

Mine flows like cold molasses through clamped off IV tubing.....

[All4NursingRN]

What are some specific problems you have in your ED paramedic?

[zmansc, ASN, RN]

OP -

You talk about issues with the flow through triage, and with the admissions process, but then your questions are about nurse/provider communication, good documentation, and managing high acuity patients. I'm confused as to what your real question is and why. What are the problems you are experiencing?

I'm not trying to ignore your issue, I can see that you have already identified some issues with triage, and potentially some with admissions. I would suggest you identify a list of issues you think could be improved so you can show the administration that you can recognize issues, but at the same time don't just take a laundry list to them, they probably already know about 80% or more of the issues you have on your list. Be able to talk about which ones are most important, you can't fix everything at once, it takes time and effort to fix each and every issue.

So the other suggestion I would have is that you identify an issue you find most important to address first, and a solution to that issue that can be implemented without significant costs, make sure you bring them the solution as well as the issue. It's also important to try to get your coworkers on board with the idea too. If you bring an idea to management and your coworkers shoot it down because it's been tried before, or even just it's different and they were not included in the solution, then there goes your chance to effect change.

In my experience, when someone brought those two items, and did so in a non threatening manner almost always get a positive response. Often their ideas were implemented, other times they at least learned about why their ideas were not feasible, and usually they were involved in discussions related to solving the problem at hand.

Finally, be prepared to discuss ER statistics like time-to-doc, etc., and use them to justify your change. Without improvement of these stats, the likelihood of the change making it through any levels of management is between zilch and nill.

[lumberjackAZRN]

The ED I workin sees on average 200 patient's a day. We are an adult ED with a total of 38 beds, 4 of which are our "critical beds" and 3 are express track beds (for acuity levels 4&5). We have a psych annex which is operated by an outside company and a quiet room for sexual assault victims. One RN and a NP run our express track beds. Other RNs each have 4pts. If you're assigned the critical beds, 2pts. We usually have 2 nurses in triage and one pivot nurse (the intake/screening nurse) who assigns beds to walk-ins. We have medics and PCTs. One PCT to 8pts and medics take on same patient load in place on PCTs but have a wider scope. We also usually have a throughput (aka discharge) nurse and a tele nurse who takes in EMS calls and helps transport critical patients.

We have shifts of 7a-7p, 9a-7p, 11a-11p, 3p-3a, 7p-7a

Our ED has gone through tremendous changes within the last 2years to improve efficiency, d/c times, admit times, waiting times, etc...

Through this change we have used what is called a LEAN philosophy. This was created by Toyota and it has had a significant impact on our ED. I'd recommend looking into it and possibly pitching it to your managers.

Also improvement within the department has also been a result of heavy collaboration with the entire hospital. In regards to ready inpatient beds. Our admitted patient wait time in our ED is now down to an average of 5 hours (this includes the time spent on the ED work up).

That's all I can think of off the top of my head. But I really suggest you look into the LEAN project. Here is a link:

What is Lean

There is so much more to it than that but it's worth looking into

[All4NursingRN]

Thanks lumberjack, I will def look into it.

[L♡vER]

Mine flows like cold molasses through clamped off IV tubing.....

Ahahahahaha! Sorta like that

[fitzfan82]

Is this Stroger (CCH),in Chicago...?