Ideas for improving flow...

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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.

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Specializes in Emergency.

What are your volumes? What happens in a code/truly emergent situation? Are the trauma rooms held for esi1 activations or do they get trauma of any flavor?

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We are a Level 4 with two Level 2s within ten minutes if going lights and sirens. We do not have a cath lab nor a neurosurgeon, so we don't get the STEMIs, Stroke Alerts, or Trauma Activations by ambulance. Things like that roll through the door by POV, in which case we stabilize and transfer. We have 2 trauma bays- one is frequently used for more serious cases, such as our ESI 2s but more commonly the 3s that are at higher risk for deterioration, and the other we try to keep open just in case. On a busy day, our volume can be about 35, but on a nice day, it can be less than 20. We have one doctor on duty at all times.

Nurse staffing is as follows: 0900-1200 2 RNs. 1200 to 1930 3 RNs. 1930-0030 2 RNs. 0030-0900 1 RN. Historically, this staffing level has worked with the volume we see, but it feels like we've seen an increase in volume in the last six months. I don't have access to the data, but what I've been told is that the numbers haven't really increased, and that management won't increase staffing unless the volume remains high over a prolonged period. Although honestly, I'm not convinced it's a staffing level issue so much as a process issue.

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Specializes in Emergency.

How do you triage now? What is the frequency of pts in the waiting room? Wait times? I would suggest starting by looking at triage, and seeing if any improvements can be made there.

Are you most interested in improving flow when there are three RNs on, or are their other times when you need to organize better as well? I believe you answered this in your original post, but currently there are no room assignments? No primary nurse for particular patients? I would agree that some form of assigning primary nurses to rooms would be helpful in that case. We run without primary nurse assignments from 0700-1000 on many days, so that the RN coming in at 1000 can be there when we make assignments. If it starts to pick up before then we often just make the assignments because it does help make things flow better.

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We run a pretty traditional triage, up at the front window, then to the waiting room to wait to be called back. If we're not busy, we can just bring the patient right back and basically "pull until full", but when we're full already, then they wait in the waiting room until there is an open bed. We probably get more acuity 4s than anything, so that's why I was thinking we should run a Fast Track with a few of our rooms- get those people in and out instead of clogging the lobby with them. On a good day, our wait times are fantastically short- people come to our ER rather than going to the big trauma center because we have a reputation for being fast. But when we get busy, wait times can be about 4 hours and then people start to LWBS or go AMA.

It's becoming more clear to me that I need to collect data and analyze it for patterns.

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Specializes in Emergency.

I understand not having a charge nurse, but who's the manager of the er? That is, who hires, fires? From the sound of it, you'll need to drive from the top down to get things changed. Have you asked for input from the other rns?

I agree with having room assignments I am also somewhat puzzled by the duplication of care issue. What exactly gets duped?

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Duplication of care, like I'll be in medicating a patient, then another RN comes into the room with the same meds, not knowing that I was in there already. Or two RNs show up with a sling or crutches. That sort of stuff, where the use of time is not efficient. If I knew someone else was already on that med or that sling, then I could be doing something else. Obviously good communication would decrease the likelihood of these things, but in the heat of the moment when we're slammed, it's really difficult to communicate with the other RNs. They're just so stressed it's like their ears are turned off. :-/

Our manager works business hours and is very involved/concerned with how things run in the department, which is a huge plus. I will be meeting with them soon to discuss this issue, and I want to have some ideas for solutions, not just a complaint.

I haven't asked for input from the other RNs specifically, but I've listened to their complaints. From what I gather, they seem to think it's a staffing issue. I've attempted to bring some organization to the chaos in the heat of the moment, but that doesn't really work because in the moment they're too frantic- it's in one ear and out the other and they just keep going on in their frantic near panic state. I agree it will have to come from the top down, but also it has to have buy in from the other RNs or it won't work, whatever it is we decide to do.

Edited to add: Room assignments are a foreign concept here, and I think there would be really significant pushback to such a proposal. I need data to support it, at the very least.

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I've been looking at other EDs who have done things like implementing "pull until full" and eliminating zone doctoring (which doesn't apply to us since we only have one doc on at a time), and having a mid level in triage (which will NEVER happen here), but I haven't been able to find out much about how having a Fast Track in a smaller ER can positively impact patient flow. Any helpful links in that direction would be appreciated.

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Specializes in Emergency.

I agree some data will probably be necessary and help. I don't have any research to help you, haven't looked really. I can tell you we operate a 10 bed ER with a 3 bed "quazi-fast track". I say quazi because 1) it's not totally separated from our ER, uses the same staff, etc. 2) Some triage RNs will fill it with lvl 2 pts and then it just becomes more of same. We started this about 1.5 years ago, and when it's used properly, it has had a dramatic effect on our patient wait times.

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Specializes in ER, progressive care.

I'm a little concerned that you only have 1 RN from 0030-0900. I realize that it's probably your least busy time but what if you get a critical patient or CPR in progress coming in? It seems to me you should have AT LEAST an extra nurse on duty for that reason. Are you a free-standing ER or attached to a hospital? Do staff from the floors respond to any codes that you have?

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I understand your concern.

Typically we do not receive CPR in progress, since they need to go to the cath lab which we don't have- unless of course, the medics can't get an airway and we're the closest facility- otherwise they're lights and sirens to one of the bigger ERs just a few minutes up the road.

Generally, our codes are those unpredictable ones, like the guy with back pain who goes into VF arrest just as the medics hit the door, or the guy who comes in by POV complaining of abdominal bloating, walking and talking one minute, pulseless the next.

Sometimes it happens in the middle of the night, but not always- which is why our ER does not hire new grads period, and only puts experienced ER nurses on night shift.

In the event of an after hours code, our code team is the ER MD, ER RN, House Supervisor (RN), M/S CN (has ACLS), the RT, and the Rad Tech/Lab Tech/Unit Secretary, all of whom can function as compressars.

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Specializes in Emergency Nursing.
I understand your concern.

Typically we do not receive CPR in progress, since they need to go to the cath lab which we don't have- unless of course, the medics can't get an airway and we're the closest facility- otherwise they're lights and sirens to one of the bigger ERs just a few minutes up the road.

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

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