LOGISTICS AND LESSONS LEARNED: ED REDESIGN

3 YEARS LATER—A FOLLOW-UP TO “HOW TO

CREATE A NEW EMERGENCY DEPARTMENT IN

21 DAYS OR LESS”

Authors: Gina Castillo, RN, BSN, CEN, and Patty Wilson, RN, CEN, Chandler, AZSection Editor: Andrew D. Harding, MS, RN, CEN, NEA-BC, FAHA, FACHE

The article entitled “How to Create a New EmergencyDepartment in 21 Days or Less” describes a processin which a 35-bed emergency department rede-

signed its process to drastically reduce turnaround time(TAT) and the number of patients who left without beingseen using existing staff and space.1 The success of the pro-cess required the willingness of the ED staff, the emergencyphysician group, and the facility administration. The newprocess has been successful in reducing TAT and the num-ber of patients who left without being seen. It has alsoincreased patient and staff satisfaction and revised the useof limited ED space. Most importantly, 100% of patientspresenting to intake are evaluated by a physician, ratherthan delaying physician evaluation until a stretcher is avail-able (the historical and antiquated triage process).

The previous article discussed the process of ED rede-sign.1 The current article is a description of the current EDpatient flow and treatment areas, including up-to-dateimprovements made to our process. We currently see anaverage of approximately 165 patients daily in the summer(May-September) and 185 patients daily during theremainder of the year in a department designed with 39patient bays. Our TAT decreased by 25%. Let’s take a tourthrough the department, to visualize the patient flow andsee the process in action.

Goodbye Triage, Hello Intake

Don’t worry: you’ll still need those nursing triage skills youhave worked to hone over the years! Our intake is a 2-stepprocess. The screening nurse performs a quick registrationof the patient on the computer while obtaining a visualassessment, pulse oximetry, and heart rate. These are docu-mented along with the respiratory status, skin status, andlevel of consciousness. Patients meeting criteria for anECG have one obtained immediately by a technician.The screening nurse performs triage, in that the nursedetermines which patient is seen next in intake. It shouldbe noted that the screening nurse still has the option toimmediately send the patient to the treatment area. Havingan ECG performed before physician evaluation assists innarrowing the physician focus or determining whetherthe patient needs the next bed. The entire screening processrequires less than 1 minute, excluding the ECG.

Physician Intake

Together, the physician and intake nurse obtain history,vitals, medications, and so on. Although this may not alltake place simultaneously (it is difficult to attain answerswhile obtaining an oral temperature!), it removes one ofthe many redundancies in the system. While emergencynurses staff intake 24 hours per day, physicians are assignedto intake 14 hours per day. During the remaining hours(11 PM to 9 AM), the on-duty physicians alternate per-forming intake. Once the patient is in a treatment area,his or her ongoing care and disposition are handled by asecond provider, either a physician or physician assistant(PA). It should be borne in mind that the intake physi-cian is responsible for both ambulatory and EMS intake.Non-intake physicians help with patient intake, bothambulatory and EMS, to assist with flow during surges.Intake requires approximately 3 minutes per patient,depending on the physician. Of note is that the intakephysician has visual contact with all patients approachingscreening at the ambulatory entrance.

Gina Castillo is Charge Nurse, Emergency Services, Chandler Regional Med-ical Center, Chandler, AZ.

Patty Wilson is Staff Nurse, Emergency Services, Chandler Regional MedicalCenter, Chandler, AZ.

For correspondence, write: Gina Castillo, MS, BSN, RN, CEN, EmergencyServices, Chandler Regional Medical Center, 475 S Dobson Rd, Chandler,AZ 85224; E-mail: GinaC@chw.edu.

J Emerg Nurs 2012;38:148-50.

Available online 13 January 2012.

0099-1767/$36.00

Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.

doi: 10.1016/j.jen.2011.11.002

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148 JOURNAL OF EMERGENCY NURSING VOLUME 38 • ISSUE 2 March 2012

Level of Care

At intake, the physician determines what level of care thepatient requires: acute, treat and disposition (TREAD), fasttrack (FT), or discharge. Acute patients require a stretcher,oxygen, monitoring, and multiple interventions. TREADpatients require a recliner and intravenous fluids and/ormedication, and they may require testing (anything fromrecurrent migraine assessment to testing to rule out appen-dicitis are treated in this area). FT patients can be seen andundergo disposition by a PA. Generally, they undergo ima-ging examinations and receive oral or intramuscular medi-cation. Finally, patients who can be discharged from intakeare seen by the physician there, are fully registered byadmitting staff, and receive their discharge instructionsfrom the triage nurse.

The intake physician orders all appropriate laboratoryand imaging examinations, as well as initial medications,regardless of route. The physician also makes a written noteof significant findings on the chart as a means of commu-nicating with the next provider. Oral medications are givenin intake by the intake nurse. Thus the treatment processbegins in intake.

The intake nurse orders the tests and fills out a “patientitinerary.” The itinerary, in both English and Spanish, is aseries of checkboxes for the following: ECG, laboratory,radiology, main or FT waiting, registration, computedtomography, and ultrasound. All ancillary departmentsare aware that the first 2 items must be completed beforeany other items. ECGs are of prime importance, anddelays in disposition will occur if the laboratory doesnot have an opportunity to draw blood from the patientbefore other examinations. Employees who perform eachof the tasks take the patient to the specified waiting areafor the next procedure. The itinerary is a fabulous patientsatisfier and reduces family and patient interruptions atthe screening or intake desk. The process is also anemployee satisfier in that the ancillary departments nolonger compete for patient access.

During our busiest hours (11 AM to 11 PM), we have onescreening nurse and two intake nurses, as well as a technicianand physician, dedicated to intake. We have three intakebays, and the physician rotates through the bays, as do theintake nurses, according to acuity and presentation time.

EMS Intake

EMS intake differs from ambulatory intake in that theEMS nurse usually is able to obtain most of her data fromthe paramedics and from viewing and interacting with thepatient. During busier times, this information is obtained,the patient is offloaded onto an ED stretcher in the EMS

hall, and if indicated, an ECG is obtained either by thenurse or a technician. Often, the patient can be screened,offloaded onto a wheelchair, and taken to the ambulatoryintake area for the remainder of intake. We strive to offloadEMS patients within 15 minutes of arrival. Once thepatient has been seen by a physician, the EMS nurse orunit secretary enters the orders and the patient moves tothe waiting or appropriate treatment area.

Challenges

Of course, space is always a challenge. Creative use of spacein the emergency department allows for quick dispositionof FT patients. An alcove, a PA, and a dedicated FT nursemake for a short TAT and a happy patient.

Another challenge faced in TREAD and FT is priv-acy. There are multiple signs in the areas notifying thepatients and visitors that requests for more private discus-sion of medical issues can be accommodated. We are ableto take patients to a private area, usually one of our pro-cedure rooms, for discussion and then return them totheir treatment area. Patients are moved to the treatmentroom long enough to perform procedures, such as pelvicexaminations, suture placement, and drainage of wounds.Patients are then returned to their assigned area, keepingthe treatment room available and helping the dischargenurse to locate them quickly.

A Nurse Is a Nurse

We have a nurse rack for alerting the treating nurse ofnew orders, calls for admissions, and so on. It also servesas a visual cue to other emergency nurses that there maybe treatment orders pending. Any emergency nurse withtime can perform those orders. In the acute area, thatnurse will generally check with the patient’s primarynurse. However, in TREAD and FT, the order is com-pleted by any nurse on duty. The chart is then placedin the physician’s rack for physician/PA assignment. Toprevent delays in care and chart searches, physicians areprohibited from removing a chart from the nurse rack,unless to briefly add orders.

Disposition: The Final Hurdle

Just as we have done for physician orders, we have workedhard to remove the “ownership” of a patient regarding dis-position, especially in the nonacute areas. Charts placed bythe physician or PA in the discharge bin are to beaddressed by any emergency nurse available. Our rule isthat “whoever types the discharge completes the dis-charge.” The rule keeps our length-of-service totals lower

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March 2012 VOLUME 38 • ISSUE 2 WWW.JENONLINE.ORG 149

and contributes to the team mentality of keeping the over-all process flow as rapid as possible.

Any emergency nurse can fax report to the floorregarding an admitted patient and can call to verify receiptof report and the name of the receiving floor nurse. Thishelps the acute emergency nurse concentrate on final vitals,assessments, and orders. It should be noted that as soon asa physician indicates that he or she plans to admit a patient,a blank admission order sheet is presented to the physician,along with the chart. This helps prevent delays at the handsof the emergency physician. The hospitalists receive fre-quent reminders from the medical committee (and theED charge nurse) that their assessments can be completedon the admitting floor.

Additional Note

As part of a 2010 corporate-wide program to improve care,each unit is required to have shift huddles before the begin-ning of the shift. This new policy has required some signifi-cant changes for staff. We use the huddles as an opportunityto review the previous day’s patient volume and TAT, bothfor admitted and discharged patients. We also review anychanges to our flow, as well as any trials that may be underway, in an effort to improve our TAT. Staff is encouraged tocome up with ideas; any well-considered change has beentrialed and evaluated for improvement in our flow. We alsouse these times to review other relevant issues to practice in

the emergency department. The 2-minute meeting hashelped to disseminate information and strengthen the teamspirit required for improving outcomes.

Summary

Although the process of redesign occurred over 3 years ago,it is important to note that ongoing revisions and trialskeep us focused on the end goal: decreased TAT andimproved patient satisfaction. The initial article about theredesign process noted that ongoing dedication to improve-ment of the emergency department and unprejudiced col-laboration toward success were required not only from theED staff but also from the entire facility.1 That statementcontinues to be true. Without flexibility and understandingfrom everyone, from ancillary departments to the chief nur-sing officer and the executive medical committee, our evo-lution would not have been, and would not have continuedto be, a success.

REFERENCE1. Castillo G, Shepard J, McHale P. How to create a new emergency

department in 21 days or less. J Emerg Nurs. 2011;37(2):165-6.

Submissions to this column are encouraged and may be sent toAndrew D. Harding, MS, RN, CEN, NEA-BC, FAHA, FACHEADHardingRN@Gmail.com

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150 JOURNAL OF EMERGENCY NURSING VOLUME 38 • ISSUE 2 March 2012