TRIAGE DECISIONS
ED GREETER NURSE: TRANSFORMING TRIAGE AND IMPROVING PATIENT CARE OUTCOMES Authors: Regina E. Nailon, PhD, RN, Shelly Schwedhelm, MSN, RN, Mary Jane Egan, RN, BSN, Suzanne Watson, RN, BSN, Suzanne L. Nuss, PhD, RN, and Rosanna Morris, MBA, BSN, NE-BC, Omaha, NE Section Editors: Andi L. Foley, MSN, RN, CEN, and Diane Gurney, MS, RN, CEN
Earn Up to 8.5 CE Hours. See page 269. D crowding is multifaceted and negatively affects patient safety. Strategies and solutions aimed at resolving crowding are necessary to successfully meet core-measure throughput metrics and achieve optimal quality. The presence of a greeter nurse was implemented at a large, Midwestern academic medical center in an effort to redesign the triage process and identify patient triage needs immediately on the patient’s arrival to the emergency department. Assessing patients as soon as they arrived to the emergency department resulted in improved performance on the time from arrival to cardiac diagnostic tests for patients with acute myocardial infarction and chest pain and on other time-sensitive quality metrics. The presence of a greeter nurse provides a safety net for patients in the waiting area that ensures that patients presenting to the emergency department are quickly assessed for prioritization and their ongoing needs are continuously analyzed. The Institute of Medicine recognizes that emergency departments across the United States are routinely over-
E
Regina E. Nailon is Clinical Nurse Researcher, Nursing Practice and Care Transitions, Nebraska Medicine, Omaha, NE. Shelly Schwedhelm, Member, Nebraska ENA Chapter, is Director of Emergency, Trauma, and Disaster Preparedness, Nebraska Medicine, Omaha, NE. Mary Jane Egan is Staff Nurse, Emergency Department, Nebraska Medicine, Omaha, NE. Suzanne Watson, Member, Nebraska ENA Chapter, is Clinical Manager, Emergency Department, Nebraska Medicine, Omaha, NE. Suzanne L. Nuss is Executive Director, Nursing Practice and Care Transitions, Nebraska Medicine, Omaha, NE. Rosanna Morris is Chief Nursing Officer and Chief Operating Officer, Nebraska Medicine, Omaha, NE. For correspondence, write: Regina E. Nailon, PhD, RN, 2133 S 46th St, Omaha, NE 68106; E-mail: [email protected]. J Emerg Nurs 2015;41:265-7. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.01.009
May 2015
VOLUME 41 • ISSUE 3
burdened, often exceeding their capacity to safely meet patient needs. 1 Barriers to patient flow in the emergency department can lead to congestion, delays in treatment, and real or potentially catastrophic patient outcomes. 2–5 Negative consequences of crowding in the emergency department include an increase in the following: care delays, numbers of patients who leave without being seen, patient deaths, medical errors, overall ED lengths of stay, ambulance diversions, and negligence claims. 3 Research shows that patients admitted to the hospital on days with high ED crowding have a greater likelihood of inpatient death, increased length of hospital stay, and increased cost per admission. 6 Furthermore, ED crowding negatively affects the emergency medical services within a community when ambulances are diverted away from crowded emergency departments or paramedics are held up by delays in the emergency department, effectively taking them out of service to respond to additional calls. 7 The emergency department at the Nebraska Medical Center experienced an unprecedented surge in patient demand during the H1N1 epidemic occurring in 2009 and 2010. During this same time frame and extending into 2011, the resources of the emergency department were profoundly challenged as patient volumes increased at a rate of 5% annually. Despite successfully managing the increased patient volumes, ED leadership and staff were not satisfied with their performance on time-sensitive metrics reflecting efficiency and safety. Furthermore, they knew that the department’s performance on time-sensitive core measures was going to be publicly reported beginning in January 2012, including a door–to–electrocardiography (ECG) time of less than 10 minutes for patients presenting with ST-segment elevation myocardial infarction (STEMI). Realizing that patient volumes would likely not decrease, and as a result of a desire to improve quality outcomes, ED leadership and staff scrutinized the triage and patient placement processes. A core team was developed to examine and address the complexities of and challenges with the triage process and resultant outcomes reflecting timeliness of patient throughput.
WWW.JENONLINE.ORG
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TRIAGE DECISIONS/Nailon et al
TABLE
ED performance on time-sensitive metrics before and after greeter nurse role creation in January 2012 Mean time (min) FY 11: Baseline FY 12: Year 1 FY 13: Year 2 FY 14: Year 3
Time Time Time Time Time
from from from from from
patient arrival to triage 9.6 placement in triage to RN evaluation 6.3 patient arrival to being seen by provider 43.9 STEMI patient arrival to ECG 7.5 STEMI patient arrival to cardiac catheterization laboratory 38.3
8.7 5.6 41.5 7.2 43.0
5.3 4.3 39.6 6.3 35.6
7.0 3.6 38.8 6.4 33.8
ECG, electrocardiography; FY, fiscal year; RN, registered nurse; STEMI, ST-segment elevation myocardial infarction.
The team began work in August 2011 by examining ED core-measure performance related to STEMI patients and patient placement processes from the previous fiscal year (FY), July 2010 through June 2011 (Table). Although performance met goals, the team identified several concerning patient outliers and, therefore, focused attention toward eliminating all outliers. The team determined that the time from arrival to ECG for patients presenting with cardiac symptoms was the most important metric on which to focus improvement efforts because treatments, such as cardiac catheterization, and outcomes for these patients relied heavily on timeliness of front-end care processes initiated on the patients’ arrival. To understand the ways ED structures and processes were influencing time from patient arrival to ECG, the team collected data over a 2-week period on all patients requiring an ECG in the emergency department. The team mapped the process of a patient’s trajectory through his or her ED visit to develop a schematic representation of all of the steps involved in the process of obtaining an ECG. Time studies were conducted to determine how long it took from patient arrival to the following: evaluation by the triage nurse, placement in a treatment room, assembly of staff and equipment, and completion of the ECG. These data showed that patients waited an average of 6.9 minutes from the time of arrival to be evaluated by the triage nurse and that, on average, it took 13 minutes from patient arrival to the time of ECG completion. After a thorough analysis of the data, the team concluded that the triage process was creating a bottleneck negatively influencing timeliness of care and patient throughput. From the data, the team was able to show ED leadership that the time from patient arrival to ECG was influenced by 3 variables: (1) the time from arrival to triage nurse evaluation, (2) delayed identification of patients in need of an ECG, and (3) the inability to bypass the triage area for immediate placement
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JOURNAL OF EMERGENCY NURSING
into a treatment room when a patient presented with cardiac symptoms. The team recommended changes to be made to the triage and intake processes to eliminate these barriers. In November 2011 the team implemented an innovative approach to the way walk-in patients were assessed, classified, and transitioned through their ED care experience, by implementing the presence of a greeter nurse. It was conceptualized that the greeter nurse would be an emergency nurse who would immediately meet and greet each patient entering the emergency department. The greeter nurse would possess the knowledge and skills to quickly assess and classify patients according to primary complaint and to identify patients who required immediate care and would be stationed at the registration desk 24 hours a day, 7 days a week. If a designated ED care area was available, the triage rooms would be bypassed and the triage nurse would immediately take the patient to a treatment room. During peak volume times from 9 AM to 11 PM, a second nurse would be assigned to the intake area to assist with completing intake assessments and placing patients in treatment rooms. To prepare the ED staff for the implementation of the greeter nurse role, the core team led 30-minute education sessions providing staff with the rationale for the changes being made and how the new structures and processes would affect ED staff roles and responsibilities. Information about the greeter nurse initiative was also provided to emergency physicians and other medical providers. The core team developed educational posters and diagrams displaying the revised throughput and patient care processes and posted these throughout the department. In January 2012 the greeter nurse role was fully assimilated into the ED care-delivery model. The impact of having a greeter nurse was immediately seen in time-sensitive metrics. The Table displays performance on targeted metrics through FY 14 compared with baseline (FY 11).
VOLUME 41 • ISSUE 3
May 2015
Nailon et al/TRIAGE DECISIONS
Improvements in performance were achieved as early as FY 12 (year 1, with the greeter nurse in place for 6 months), and more significant improvements occurred over the next 2 years. The average time, in minutes, from patient arrival to placement in triage has steadily decreased and remains lower than baseline. The time from patient arrival to evaluation by the triage nurse has decreased to 3.6 minutes. The time from STEMI patient arrival to ECG now averages 6.4 minutes. The time from STEMI patient arrival in the emergency department to arrival in the cardiac catheterization laboratory has decreased by 4.5 minutes since baseline. The mean time from patient arrival to evaluation by a qualified medical provider has improved steadily, contributing to the improved door–to–cardiac catheterization time. Nurses acting in the greeter nurse role have indicated they feel more empowered to make decisions regarding patient needs, including the rapid initiation of clinical protocols. The greeter nurse innovation has further evolved to the current state in which the oncoming nurse assigned to the greeter nurse role receives report from the greeter nurse leaving his or her shift so that there are no gaps in surveillance and monitoring of patients in the waiting area. Crowding in the emergency department has major implications for patient throughput and the ability to successfully achieve optimal outcomes. Assessing patients as soon as they arrived to the emergency department resulted in improved performance on the time from arrival to ECG
May 2015
VOLUME 41 • ISSUE 3
for patients with acute myocardial infarction and chest pain and has also positively influenced other core measures and time-sensitive metrics. REFERENCES 1. Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point, Washington, DC: The National Academies Press; 2007. http://books. nap.edu/openbook.php?record_id=11621. Accessed June 5, 2014. 2. Carter EJ, Pouch SM, Larson EL. The relationship between emergency department crowding and patient outcomes: a systematic review. J Nurs Scholarsh. 2014;46:106-115. 3. ACEP Task Force Report on Boarding. Emergency Department Crowding: High-Impact Solutions, Washington, DC: American College of Emergency Physicians; 2008. 4. Bellow AA, Gillespie GL. The evolution of ED crowding. J Emerg Nurs. 2014;40:153-160. 5. Cohen S. Perspectives on emergency department throughput. J Emerg Nurs. 2013;39:61-64. 6. Sun BC, Hsia RY, Weiss RE, et al. Effects of emergency department crowding on outcomes of admitted patients. Ann Emerg Med. 2012;20:1-7. 7. Eckstein M, Chan LS. The effect of emergency department crowding on paramedic ambulance availability. Ann Emerg Med. 2004;43:100-105.
Submissions to this column are encouraged and may be sent to Andi L. Foley, MSN, RN, CEN [email protected] or Diane Gurney, MS, RN, CEN [email protected]
WWW.JENONLINE.ORG
267
ED GREETER NURSE: TRANSFORMING TRIAGE AND IMPROVING PATIENT CARE OUTCOMES Authors: Regina E. Nailon, PhD, RN, Shelly Schwedhelm, MSN, RN, Mary Jane Egan, RN, BSN, Suzanne Watson, RN, BSN, Suzanne L. Nuss, PhD, RN, and Rosanna Morris, MBA, BSN, NE-BC, Omaha, NE Section Editors: Andi L. Foley, MSN, RN, CEN, and Diane Gurney, MS, RN, CEN
Earn Up to 8.5 CE Hours. See page 269. D crowding is multifaceted and negatively affects patient safety. Strategies and solutions aimed at resolving crowding are necessary to successfully meet core-measure throughput metrics and achieve optimal quality. The presence of a greeter nurse was implemented at a large, Midwestern academic medical center in an effort to redesign the triage process and identify patient triage needs immediately on the patient’s arrival to the emergency department. Assessing patients as soon as they arrived to the emergency department resulted in improved performance on the time from arrival to cardiac diagnostic tests for patients with acute myocardial infarction and chest pain and on other time-sensitive quality metrics. The presence of a greeter nurse provides a safety net for patients in the waiting area that ensures that patients presenting to the emergency department are quickly assessed for prioritization and their ongoing needs are continuously analyzed. The Institute of Medicine recognizes that emergency departments across the United States are routinely over-
E
Regina E. Nailon is Clinical Nurse Researcher, Nursing Practice and Care Transitions, Nebraska Medicine, Omaha, NE. Shelly Schwedhelm, Member, Nebraska ENA Chapter, is Director of Emergency, Trauma, and Disaster Preparedness, Nebraska Medicine, Omaha, NE. Mary Jane Egan is Staff Nurse, Emergency Department, Nebraska Medicine, Omaha, NE. Suzanne Watson, Member, Nebraska ENA Chapter, is Clinical Manager, Emergency Department, Nebraska Medicine, Omaha, NE. Suzanne L. Nuss is Executive Director, Nursing Practice and Care Transitions, Nebraska Medicine, Omaha, NE. Rosanna Morris is Chief Nursing Officer and Chief Operating Officer, Nebraska Medicine, Omaha, NE. For correspondence, write: Regina E. Nailon, PhD, RN, 2133 S 46th St, Omaha, NE 68106; E-mail: [email protected]. J Emerg Nurs 2015;41:265-7. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.01.009
May 2015
VOLUME 41 • ISSUE 3
burdened, often exceeding their capacity to safely meet patient needs. 1 Barriers to patient flow in the emergency department can lead to congestion, delays in treatment, and real or potentially catastrophic patient outcomes. 2–5 Negative consequences of crowding in the emergency department include an increase in the following: care delays, numbers of patients who leave without being seen, patient deaths, medical errors, overall ED lengths of stay, ambulance diversions, and negligence claims. 3 Research shows that patients admitted to the hospital on days with high ED crowding have a greater likelihood of inpatient death, increased length of hospital stay, and increased cost per admission. 6 Furthermore, ED crowding negatively affects the emergency medical services within a community when ambulances are diverted away from crowded emergency departments or paramedics are held up by delays in the emergency department, effectively taking them out of service to respond to additional calls. 7 The emergency department at the Nebraska Medical Center experienced an unprecedented surge in patient demand during the H1N1 epidemic occurring in 2009 and 2010. During this same time frame and extending into 2011, the resources of the emergency department were profoundly challenged as patient volumes increased at a rate of 5% annually. Despite successfully managing the increased patient volumes, ED leadership and staff were not satisfied with their performance on time-sensitive metrics reflecting efficiency and safety. Furthermore, they knew that the department’s performance on time-sensitive core measures was going to be publicly reported beginning in January 2012, including a door–to–electrocardiography (ECG) time of less than 10 minutes for patients presenting with ST-segment elevation myocardial infarction (STEMI). Realizing that patient volumes would likely not decrease, and as a result of a desire to improve quality outcomes, ED leadership and staff scrutinized the triage and patient placement processes. A core team was developed to examine and address the complexities of and challenges with the triage process and resultant outcomes reflecting timeliness of patient throughput.
WWW.JENONLINE.ORG
265
TRIAGE DECISIONS/Nailon et al
TABLE
ED performance on time-sensitive metrics before and after greeter nurse role creation in January 2012 Mean time (min) FY 11: Baseline FY 12: Year 1 FY 13: Year 2 FY 14: Year 3
Time Time Time Time Time
from from from from from
patient arrival to triage 9.6 placement in triage to RN evaluation 6.3 patient arrival to being seen by provider 43.9 STEMI patient arrival to ECG 7.5 STEMI patient arrival to cardiac catheterization laboratory 38.3
8.7 5.6 41.5 7.2 43.0
5.3 4.3 39.6 6.3 35.6
7.0 3.6 38.8 6.4 33.8
ECG, electrocardiography; FY, fiscal year; RN, registered nurse; STEMI, ST-segment elevation myocardial infarction.
The team began work in August 2011 by examining ED core-measure performance related to STEMI patients and patient placement processes from the previous fiscal year (FY), July 2010 through June 2011 (Table). Although performance met goals, the team identified several concerning patient outliers and, therefore, focused attention toward eliminating all outliers. The team determined that the time from arrival to ECG for patients presenting with cardiac symptoms was the most important metric on which to focus improvement efforts because treatments, such as cardiac catheterization, and outcomes for these patients relied heavily on timeliness of front-end care processes initiated on the patients’ arrival. To understand the ways ED structures and processes were influencing time from patient arrival to ECG, the team collected data over a 2-week period on all patients requiring an ECG in the emergency department. The team mapped the process of a patient’s trajectory through his or her ED visit to develop a schematic representation of all of the steps involved in the process of obtaining an ECG. Time studies were conducted to determine how long it took from patient arrival to the following: evaluation by the triage nurse, placement in a treatment room, assembly of staff and equipment, and completion of the ECG. These data showed that patients waited an average of 6.9 minutes from the time of arrival to be evaluated by the triage nurse and that, on average, it took 13 minutes from patient arrival to the time of ECG completion. After a thorough analysis of the data, the team concluded that the triage process was creating a bottleneck negatively influencing timeliness of care and patient throughput. From the data, the team was able to show ED leadership that the time from patient arrival to ECG was influenced by 3 variables: (1) the time from arrival to triage nurse evaluation, (2) delayed identification of patients in need of an ECG, and (3) the inability to bypass the triage area for immediate placement
266
JOURNAL OF EMERGENCY NURSING
into a treatment room when a patient presented with cardiac symptoms. The team recommended changes to be made to the triage and intake processes to eliminate these barriers. In November 2011 the team implemented an innovative approach to the way walk-in patients were assessed, classified, and transitioned through their ED care experience, by implementing the presence of a greeter nurse. It was conceptualized that the greeter nurse would be an emergency nurse who would immediately meet and greet each patient entering the emergency department. The greeter nurse would possess the knowledge and skills to quickly assess and classify patients according to primary complaint and to identify patients who required immediate care and would be stationed at the registration desk 24 hours a day, 7 days a week. If a designated ED care area was available, the triage rooms would be bypassed and the triage nurse would immediately take the patient to a treatment room. During peak volume times from 9 AM to 11 PM, a second nurse would be assigned to the intake area to assist with completing intake assessments and placing patients in treatment rooms. To prepare the ED staff for the implementation of the greeter nurse role, the core team led 30-minute education sessions providing staff with the rationale for the changes being made and how the new structures and processes would affect ED staff roles and responsibilities. Information about the greeter nurse initiative was also provided to emergency physicians and other medical providers. The core team developed educational posters and diagrams displaying the revised throughput and patient care processes and posted these throughout the department. In January 2012 the greeter nurse role was fully assimilated into the ED care-delivery model. The impact of having a greeter nurse was immediately seen in time-sensitive metrics. The Table displays performance on targeted metrics through FY 14 compared with baseline (FY 11).
VOLUME 41 • ISSUE 3
May 2015
Nailon et al/TRIAGE DECISIONS
Improvements in performance were achieved as early as FY 12 (year 1, with the greeter nurse in place for 6 months), and more significant improvements occurred over the next 2 years. The average time, in minutes, from patient arrival to placement in triage has steadily decreased and remains lower than baseline. The time from patient arrival to evaluation by the triage nurse has decreased to 3.6 minutes. The time from STEMI patient arrival to ECG now averages 6.4 minutes. The time from STEMI patient arrival in the emergency department to arrival in the cardiac catheterization laboratory has decreased by 4.5 minutes since baseline. The mean time from patient arrival to evaluation by a qualified medical provider has improved steadily, contributing to the improved door–to–cardiac catheterization time. Nurses acting in the greeter nurse role have indicated they feel more empowered to make decisions regarding patient needs, including the rapid initiation of clinical protocols. The greeter nurse innovation has further evolved to the current state in which the oncoming nurse assigned to the greeter nurse role receives report from the greeter nurse leaving his or her shift so that there are no gaps in surveillance and monitoring of patients in the waiting area. Crowding in the emergency department has major implications for patient throughput and the ability to successfully achieve optimal outcomes. Assessing patients as soon as they arrived to the emergency department resulted in improved performance on the time from arrival to ECG
May 2015
VOLUME 41 • ISSUE 3
for patients with acute myocardial infarction and chest pain and has also positively influenced other core measures and time-sensitive metrics. REFERENCES 1. Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point, Washington, DC: The National Academies Press; 2007. http://books. nap.edu/openbook.php?record_id=11621. Accessed June 5, 2014. 2. Carter EJ, Pouch SM, Larson EL. The relationship between emergency department crowding and patient outcomes: a systematic review. J Nurs Scholarsh. 2014;46:106-115. 3. ACEP Task Force Report on Boarding. Emergency Department Crowding: High-Impact Solutions, Washington, DC: American College of Emergency Physicians; 2008. 4. Bellow AA, Gillespie GL. The evolution of ED crowding. J Emerg Nurs. 2014;40:153-160. 5. Cohen S. Perspectives on emergency department throughput. J Emerg Nurs. 2013;39:61-64. 6. Sun BC, Hsia RY, Weiss RE, et al. Effects of emergency department crowding on outcomes of admitted patients. Ann Emerg Med. 2012;20:1-7. 7. Eckstein M, Chan LS. The effect of emergency department crowding on paramedic ambulance availability. Ann Emerg Med. 2004;43:100-105.
Submissions to this column are encouraged and may be sent to Andi L. Foley, MSN, RN, CEN [email protected] or Diane Gurney, MS, RN, CEN [email protected]
WWW.JENONLINE.ORG
267
