Preparing for Patient Demand Under Reform: Does Your ED Need an Overhaul?

HUNT: Technology integration has been a net positive, but there have been some negatives, too. We've been on patient tracking for several years, and that's undoubtedly been a huge benefit, as is having immediate access to medical records. Our physicians have been using CPOE for more than three years, and that's been more of a mix. Some things are excellent about it—for instance, the drug interaction and allergy checking is a big safety improvement. One downside has been that some of the physicians feel that in our system it's potentially easier to enter orders on the wrong patient than it was when you had to physically pick the chart out of the rack. I think the real unforeseen consequence has been that it tends to pull attention away from the patient's bedside and direct it toward the computer and nursing unit. This has been particularly noticeable as nurses moved to computerized documentation, despite having computers in every room. Good care is still being delivered, but the patients in particular miss the bedside interactions. If I were starting from scratch in the ED, I would look hard for a best-in-breed ED solution and then make it interface with the inpatient system.

WHITE: We had a different experience. In the ED, we were the first ones in the hospital to go completely to an electronic record. We were very careful about how we chose that vendor and really did a lot of analysis prior. That happened three years ago. For us it's really been beneficial. It's provided us with a lot of benefits in terms of turnaround time and patient experience. Our approach was to de-anchor nurses from going behind the nurses' station. If you get the nurse away and they're doing that clerical work, they're not at the bedside. We have stand-up units, we have carts, we have tablets, and we've got wall-mounted units in the rooms.

DAVIS: We use a patient tracker board, but we're just now putting in CPOE. All of us on the ED project are fairly nervous because of the volume of patients we see and we're concerned about a slowdown. A normal anxiety is making sure we are productive and effective at meeting our patients' needs in a timely manner.

MASSINGALE: For more than 10 years we've made big investments in IT because we believe in the necessity of having actionable data. We have 130 full-time IT employees just in our organization. So we're all about IT. We have a full-time clinical informatics officer who serves as a wonderful interface between the IT people and the doctors. He helps us communicate with each other and he's been a huge advantage. But it's not easy to find that kind of support.

HEALTHLEADERS: Let's talk about staffing outside of doctors and nurses. Do any of you have one person or one group of people who's responsible for reaching your throughput goals?

HUNT: We have groups looking not only at improving throughput, but also at ways to better keep the people who are waiting informed how long it is going to be, where they are in line, and what they can expect next. Everybody needs to share that task, but it would also be nice to have somebody whose job it is to make sure patients get a warm blanket, food or water, or keep them informed when the physicians and nurses are busy with others.

DAVIS: Our goal is to decrease the wait time, and we decided to focus our resources on that, knowing it is a team effort. We made it all of our jobs to provide timely care for patients coming to us. We do have a hospitalwide patient liaison who assists our leaders in service recovery.

MASSINGALE: We have worked in places off and on through the years that have a patient care coordinator or somebody who does some of those things. One of our regions has used scribes. They actually call the scribes CIMs or clinical information managers, and in addition, they created the medical record. They're the ones who keep the family informed and they bird-dog the lab results.

WHITE: At Tomball, the responsibilities of that job are shared between the house supervisor, who's motivating folks to pull from the emergency department, and the ED charge nurse. I really push my clinical manager and my ED charge nurses to be rounding on the patients and their families and to always be moving and looking for the roadblocks. We use specific tools to identify where those roadblocks are.

HUNT: We have new leadership at Mission who see the importance in efficiency. We are in the process right now of creating a systemwide patient throughput team with some smaller working groups that will be doing cycles of 90-day process improvement projects. They'll be starting at both the admission and discharge ends, working their way to the middle. So I'm quite hopeful that we're going to see a lot of throughput improvements systemwide. It is important to realize that throughput can't be focused only on the ED and it must originate from the top levels of administration. Someone has to take ownership of it from the leadership's perspective. It can't be left for the ED to fix from the bottom up. It just won't happen that way.

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