Increased Patient Volume - Suggestions needed

[lilbitgeeky]

I'll apologize in advance for this being long, but I'm looking for some advice. I'll start by saying I love the ER where I work and my coworkers are awesome team players.

However, we've been seeing an increase in our patient wait time. We've gone from having a max wait of about 2 hours to the average wait every night from 6p-11p being about 2-3 hours. Some patients are waiting as long as 4-5 hours just to be placed in a room. It's common for an ER visit to be 6-9 hours for simple workups.

I know that this may be common in some parts of the country, but this is a recent development for us. We've made a number of changes. We started zone nursing and doctoring in order to accommodate the fact that we went from having 3 providers from 3p-11p to never having more than 2 providers on. We've added 2 new rooms to our ER. We've done some renovating and now have a new waiting room, check in area and triage room.

Overall, our changes are wonderful, except the fact that we got rid of a provider. We are currently working on a plan to get another provider/midlevel, but I'm told it will be at least 4 months.

My issues are:

1. How can we better handle the customer service aspect of this? Staff (from nursing to patient registration) are hesitant to tell people the harsh truth of: If it isn't killing you at this moment you may be in the ER over 6 hours to get treated. I feel like this comes from a place of not wanting to anger or disappoint people, but what can we say/do to encourage our staff to just be honest about the wait time without fearing getting yelled at by the patients?
   
2. Patient expectations are unrealistic. Our managers have talked with patients who were both pleased and unpleased with their visits and the consensus is that our patient population is expecting to be updated every 15 minutes, whether they are in the waiting room or in an exam room! Our standard currently is that we will round on every patient in an exam room at least every hour, with patients who are an ESI 1-2 having q15 minute vital signs. We do not really have a standard for updating waiting room patients. We do an eyeball assessment every hour, and are supposed to be getting new vitals every 2 hours, but the triage nurse is usually too busy for this. How do you go about updating patients in your waiting room on changes in wait time? How often are your patients in beds being checked in on?
   
3. Some of our providers are SLOW! I hate saying this, because they are wonderful doctors and care about their patients, but it doesn't change the fact that a majority of our providers have patients wait over an hour from the time they are placed in a room to the time they are seen. We have few triage protocols so we are unable to start labs until the provider sees the patient, unless you can convince them of your awesome nursing assessment and get them started. I have talked to my manager and we are going to trial setting a limit that a pt needs a disposition plan once they have been in bed for 4 hours. Is this the norm? How can we help our doctors speed up their process?
   

Our staff works well together as a team, but there has been a lot more stress and it is taking it's toll. Things are getting missed because the later the waiting room is full the fewer nurses we have and the more patients each nurse is taking. And simply having a waiting room full of patients makes everyone a little more stressed out. Our AMA and LWBS numbers are sky rocketing. Any suggestions?

[Anna Flaxis, BSN, RN]

You need to develop your nurse initiated protocols! At least this way, much of the workup will already be completed by the time the doc darkens the door.

[Esme12, ASN, BSN, RN]

I agree...your triage driven order sets to get the ball rolling.

Having set protocols for labs IV and x-rays is imperative for the providers to have all of this available while the patient waits.

For example...

Chest pain...EKG, heploc, Cardiac enzymes, PT, PTT CXR with parameters for O2 and nitro if necessary.

Abd pain....Heploc, CBC, amalayse, Lipase, acute abdominal series, UA C/S, UCG

Psych eval/detox...basic CMP, CBC, EToH, UA tox screen, Banana bag for ETOH

Injury...allowed to order x-rays from triage.

Lacs....application of LAC when applicable.

and so forth....this makes the patient know that "something" is being done.

The charge or triage monitor the waiting room. ANY communication is good. We had pamphlets and signs all over the place about when they would be checked on and information about the process. Be honest and up front with patients. Start in triage. "We are very busy and have a xyz wait time right now. We will keep you informed and do some labs/x-rays in the mean time. We will take care of you" Have protocols for Tylenol/ibuprofen from triage

Slow MD's...they re a problem. You need a strong medical director to help keep them in line. Start with all admissions need to be done 90 mins before shift change. Limit on work up times so they don't do the entire w/u in the ED. Limit on dispo times....if you can't get them out in 3 ours they are an admit. Period.

[traumaRUs, MSN, APRN]

Have screening exams done at triage by APN and then turf no urgent matters to either your fast track or their PCP.