Published: Synapse 2013, Vol. 3
Unexpected illnesses and injuries happen every day, and even minor ailments can mean a trip to a local emergency room. Nobody looks forward to heading through those doors at any hospital, but far too often a lot of the apprehension associated with the visit has to do with the hassles and inconveniences of getting through a process that can seem needlessly long and cumbersome.
When your condition doesn't require immediate medical attention, a visit to a typical emergency room can seem like an endless series of stops and starts and a whole lot of waiting and repetition as you move through the system. The experience may end up feeling similar to the ordeal of a slow bus ride to an important destination. You know you will get there eventually, but you have no idea how long the trip will take or how many stops will be made along the way.
A visit to the Chester County Hospital's re-envisioned Emergency Department (ED) will quickly change your perspective on what an emergency room visit can and should be. The hospital has transformed its emergency care delivery system to create a whole new process and a brand new experience for patients. The entire system has been streamlined and fine-tuned. The hospital has found a faster, more efficient way to continue providing the highest quality care possible while improving the overall experience for each and every person visiting the Emergency Department.
"We decided to really look at how our ED was functioning to see if we could make the process easier for our patients. We brought together a team of people to design a better system that would ultimately allow us to begin treatment faster," explains Betty Brennan, EdD, MSN, RN, CEN, Director of Emergency Services. "First, we said 'Let's be smarter. Let's put the people who do the ordering up front.' That meant having patients see a doctor right away instead of further along in the process. Then we looked at what other changes we could make to shorten the length of time between when our patients walk in the ED door and when they are either discharged back home or admitted to the hospital."
The traditional model for treating a patient in an emergency room setting was built around the paradigm that medical care must be delivered on a hospital bed or stretcher. How long it took for each ED patient to make it to a bed and see a doctor depended upon their physical condition and needs upon arrival and, of course, the number of patients already being treated in the ED at any given time. Rightfully so, people with more serious, life-threatening conditions moved more swiftly through the system. For those with needs that are relatively less severe, however, the old ED process easily became a succession of evaluations, encounters and empty gaps while waiting for a bed to become available or for treatment to begin.
Christopher Ware, MD, Vice Chair of Emergency Medicine, says "We've taken ourselves out of the model where everybody needs a bed. Everybody doesn't need a bed. Some patients may only need a 15-minute evaluation by a physician, a simple test or two, or maybe a prescription and a follow-up discussion about what to do when they're discharged. With the old system, these patients were thrown into a model that treated them the same as a heart attack or stroke victim. That doesn't make sense."
Prior to the new process taking place in May 2013, it would take an average of 50-70 minutes for a patient to see a physician. Today with these outside-the-box changes, the average wait time to see a physician is now just 9-10 minutes.
"Our new system places patients with more acute or critical conditions into beds, while less sick patients are able to remain dressed and upright during care," Ware explains. "Patients are evaluated right away by a physician or physician assistant who is able to make an early determination about which patients truly need to lay down on a bed and which patients don't. Now, we can begin addressing our patients' medical issues from the moment they walk in. Treatment begins immediately for everyone, and we can quickly move patients on to the next stage of their care, whether that's toward discharge, further testing or hospital admission."
In a customary ED setting, patients are assessed by multiple people at various points as they move through the system, often having to repeat the same story and answer the same questions multiple times. Patients entering the Chester County Hospital's revamped ED now spend just a few minutes at the front desk providing their names to be entered into the system, with full registration at a more convenient time later in the process. They then move very quickly to a special area near the front of the department where they see a triage team, including an Emergency Department physician and/ or physician assistant, as well as nurse. Patients now tell their story once to this team of experts who are able to ask questions, do some preliminary testing, make a diagnosis, and place orders for treatment along with any additional tests that may be needed.
While patients with more serious or complicated conditions are moved directly to a traditional ED bed, some of the patients with conditions of a less serious nature may be able to receive whatever treatment is needed right then and there during their visit with the triage team. For example, the doctor may decide that a patient with a sinus infection needs only a prescription and some instructions before heading home. In these cases, the patient can be discharged without progressing any further through the system.
Patients who do not need a hospital bed but do require further testing or treatment are escorted to what is called the Rapid Treatment Area, where they can sit comfortably and remain dressed while being continuously monitored by a nurse.
"Patients in our Rapid Treatment Area are able to stay in an environment that isn't quite as disconcerting or clinical as a more traditional ED treatment space. Their care really began at the door of the ED when they saw the doctor and triage nurse. Orders have already been placed to get their care started. The doctor may have wanted some lab work, x-rays or an EKG or may have ordered pain medication, IV fluids or something for nausea," explains Diana Kane, MD, Chair of Emergency Medicine.
"Radiology is adjacent to the rapid treatment waiting area so if x-rays are needed, a technician will come and get the patient. The patient changes into a hospital gown in the privacy of the Radiology Department and comes back fully dressed again. Any other tests or treatments also take place in private. When the time comes, patients are discharged and on their way home having received the attention and care they needed usually far more comfortably and much faster than they had expected."
Conceptualizing and then creating such a positive experience for ED patients was a huge undertaking that took commitment and involvement from across the Emergency Department and at all levels of the hospital. Reconfiguring the old system meant evaluating and redesigning processes, redirecting resources, remodeling physical structures, increasing staffing, and shifting the mindset of people who were used to things being done a certain way.
Made possible through the generosity of several private donors, the new patient care system was built and the process refined by the people who live it every day and understand it best - the ED technicians, ED nurses, ED physicians, and ED physician assistants. Everyone supplied input from their perspective on how to make changes that would streamline and improve the system. And Betty Brennan, Dr. Kane and Dr. Ware all agree that the evolution was made possible because of the steadfast commitment and support of hospital administrators.
"To really take this on and make it work, it had to be a total team effort," says Dr. Ware.
"Change isn't easy and it doesn't just happen. I think the success of this system has a great deal to do with the enthusiasm for it at every level... the leadership shown at the administrative level, the total involvement and commitment of our nursing team, the contributions of our techs, and the engagement and active participation of the medical staff. Together, we developed a system unique to our hospital, our patients and our physical layout."
According to Dr. Ware, the care and attention to detail that the team put into the initial planning stages may have made all the difference. "It took us probably a good year of preemptive meetings, work-flow modeling and setting everything up in just the right way to have this work well out of the gate," he explains. "The time and effort involved prior to implementing the new system has reaped significant dividends. It has been and continues to be a smooth transition."
Since the new system went live this spring, its success has become evident in many ways. All metrics measured by the hospital confirm that the new system is having a significantly positive impact in the ED. Patient satisfaction is up. Staff satisfaction is up. Waiting times are down. Patient flow has improved, which means patients are in and out of the system much faster.
In addition, there has been a drastic reduction in the number of patients who check in at the Emergency Department only to leave without being seen by a doctor. "Left without being seen" (LWBS) statistics are often used to determine how well an ED is functioning. According to Brennan, Chester County's new system has reduced the number of LWBS patients at Chester County's ED by more than 90 percent.
"This process is working and it will continue to work because we will continue to adapt it to meet our patients' needs and the situations we face each day," says Dr. Kane. "After all, the ED is like a living, breathing thing. Each day has its own personality and it can be unpredictable. There are days when everyone who comes through our doors is absolutely as sick as can be and other days when we see only minor issues. But with our new system, we've found a process that allows our focus to remain on starting the appropriate medical care sooner rather than later for every patient we see. It respects our patients' time and puts our patients' needs above all else."
By Beth Eburn
Photos by Rick Davis
The Emergency Department modification was complemented by additional monitored beds opening in the Lasko Tower, as well as an ED protocol change that accelerated the throughput of low-risk chest pain patients.