May 29, 2008 ENCORE Questions and Answers The Long and Winding Road: From Chaos to Efficient Patient Flow Participant Melinda Stibal, RN, MBA

Thank you for your participation in ENA's ENCORE Web seminar series. The following are the questions submitted by participants during the The Long and Winding Road: From Chaos to Efficient Patient Flow Participant presentation. The questions have been answered by the presenter, Melinda Stibal. For clarification, please contact Melinda directly at mstibal@mhs.net.

1. How did you get buy-in from ED nursing staff?
   We started by making sure the nursing staff had the basic resources they needed to care for the patients, some of which were lacking (working equipment, enough pumps, NIBPs, etc.). We then started working with the “toxic” few, taking them out of charge and trauma positions, even as informal leaders, taking them out of these positions really made a difference.

2. What does VHA stand for?
   Voluntary Hospital Association

3. What were the top three reasons they went through ED directors?

   1) Lack of ED experience and making large scale change happen. 2) Staff chewed them up. 3) Unrealistic expectations from administration coupled with a lack of appropriate resources.

4. What does "triage" process entail before patient is moved to a bed?
   Chief complaint, vitals, brief medical history, meds, and brief nursing assessment.

5. In your metrics, what percentage of beds were pre-reserved but not eventually needed?
   Our cancellations are pretty miniscule, and if we do cancel an admission, there is usually someone waiting. We do not measure this metric but if we cancel 10 of our 2000 monthly admission a month it would be a lot.

6. Is your ED using an electronic Medical record for all patients?
   No, we have a bed tracker, and a clinical informatics system but it has not reached to nursing or physician documentation as of yet. CPOE is the next step for us.

7. How did you combat departmental silo behavior?
   My executive team did that for me, when they set the expectations and hold other departments accountable it makes a difference. We also did internal things such as 1:1 rounding, me and the ancillary department director, wide praise of nursing units who reduced order to bed times; we tried to recognize everyone who contributed to the effort. We have an unsung hero each month. This is recognition for someone who has made a positive impact on our department, their picture goes up on a bulletin board in the ED, the entire staff thanks them when they see them in the department and we send a letter of accommodation to their supervisor/leader.

8. What triage system does your staff use?
   ESI IV

9. Are you using electronic charting or paper?
   Paper

10. How did you deal with nurse push back when asking the nurses to take higher patient ratios?
    We explain that the most dangerous place in our hospital is the waiting room and talk about some of the horror stories that have happened in the news or in other EDs. We attempt to assist by facilitating flow of discharged and admitted patients. The entire management staff pitches in with charting patients in, starting an IV, dropping a NGT or giving a med or covering lunches whenever possible.

11. What is the ACBD sheet from the handouts?
    This is our patient distribution system; there is one sheet for triage and another for EMS.

    The first patient that arrives goes to POD A, then POD B and so on…each POD gets 1:4 patients so no area gets slammed at once. Each POD consist of 16 beds; 1 doc, 1 Charge Nurse, 4 bedside nurse, 1 UC, and 1 tech (we try to add a second during 11a-11p whenever possible).

    My productive RN hours per UOS run anywhere from 1.90 to 1.98 on average, this is actual bedside time and includes the charge nurses and triage. This probably seems pretty high to many people but it really makes a difference on our efficiency. We see a large shift when the RN hours drop to below 1.90. We follow the ENA staffing guidelines for an 87/13% split of RN’s to assistive staff.

12. We don’t have bedside registration at our facility. Is that fact a large barrier in your opinion to heads in beds?
    Bedside registration is crucial to moving patients to the back, only a mini-reg is done up front; name, DOB, SS#, chief complaint. That’s enough to generate a billing number and either create a MR# or match a previous one. We are a very conservative organization from a legal/risk management standpoint and do not register patients until seen by an EDP.

13. Would you better explain the triage call overhead? What happens to Triage 1-4 - do the nurses in the back bring back T5 - T6, . . . or the first in the door?
    We work it first in, first out. Each of the 4 charge nurses go to triage, they bring back the next 4 patients who are signed in. If the back is so busy that this is not possible, the clinical manager (shift manager) goes to triage and grabs 4 patients and assigns them to treatment areas. The reason we started this was the fact that it is very easy to lose sight of what is going on in triage when you are in the treatment area. This keeps front of mind awareness going.

    By the way, the staff really hates it. It’s a topic of conversation at every staff meeting. I listen to them and then go through the whole “the waiting room is the most dangerous place in our hospital” routine and let them know that this is not a negotiable item. This of course is done in a polite, courteous, get over it, manner. To date, no one on my staff has come up with a better way of dealing with a backed up waiting room, so until then we will continue to do “T” announcements.