Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Cutting-edge Discussions

of Management, Policy, and Program Issues

in Emergency Care

M A N A G E R S F O R U M

Polly Gerber Zimmermann, RN, MS, MBA, CEN

Physician and Registered Nurse in Triage

Same Level of Care for Admitted ED ‘‘Holds’’

Determining the Number of Needed ED Beds

Abdominal Pain Triage Protocols

Hours Per Patient Visit

Mobile Versus Stationary Patient Care Computers

Registered Nurses Removing Sutures

Selecting an EDIS

The opinions expressed are those of the respondents and should not beconstrued as the official position of the institution, ENA, or the Journal.

J Emerg Nurs 2006;32:435-41.

Available online 7 August 2006.

0099-1767/$32.00

Copyright n 2006 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2006.05.027

October 2006 32:5

PHYSICIAN AND REGISTERED NURSE IN TRIAGE

I have heard that some emergency departments place an

ED physician in the triage area or use teams of a physician

and a registered nurse (RN) to improve the patient care

process. How does that system work, and is it effective?

Answer 1:

Our emergency department needed a drastic change. We

have many elderly patients (28% retired), with a high pa-

tient acuity. Our ED volume had increased from 120 to

180 patients a day and, as a result, we were averaging a

wait-to-be-seen time of 8 to 10 hours. Fourteen percent of

our patients left without being seen (LWBS), and the

average length of stay (LOS) was 6 to 8 hours (8 to 9 hours

if admitted). Not surprisingly, our patient satisfaction scores

were only 9%.

We sought to change by taking a rapid-cycle improve-

ment approach, using a team composed of members from

each discipline, to create a staff-driven redesign. We created

a system similar to a disaster triage format. There are 2 in-

take teams of a physician and RN in the traditional triage

area. (Fast track was eliminated.) These teams assess the

walk-in patients, fill out one form together, and write the

initial orders. The team processes the majority of our walk-

in patients within 15 minutes of arrival.

There are 2 ‘‘quick procedure’’ rooms, staffed by a

physician assistant. These areas are used for minor su-

turing, splinting, foreign body removal, or extensive dis-

charge instructions. If the patient needs blood work, he

or she next is taken to the specimen area. From there, a pa-

tient is placed either in an emergency treatment bed or in

the patient ‘‘lounge.’’

The lounge has recliners and amenities such as a play

station and movies; it is where we place 40% to 50% of

our patient population. Patients are taken from here for

JOURNAL OF EMERGENCY NURSING 435

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M A N A G E R S F O R U M / Z i m m e r m a n n

any additional diagnostic tests, such as radiographs, and/or

to receive intravenous f luids. Volunteers regularly round

within the area to offer comfort measures.

The ambulance arrival area has a paramedic greeter

who ‘‘sorts’’ the patients. Approximately 50% to 70% of

this population goes into ED treatment beds.

If there is an unusually large inf lux of patients, we

set up extra chairs and have the intake team at least

‘‘touch and talk’’ to each patient initially, similar to a disas-

ter scenario. The patients then are prioritized for a more

thorough intake.

Other hospital-wide changes were implemented to

support our process and the ED patient f low needs. Our

ancillary services are quick: laboratory turnaround time is

40 minutes, and radiograph turnaround time is 30 min-

utes. Admitted patients now go up to the f loor within

60 minutes. Report is taken even if it is shift change time

and, if necessary because of a lack of an available bed, the

inpatient unit sets up a transition unit.

The implementation phase for such drastic changes

is crucial. We took 1 week to work on the design of this

new process, 1 week for setting up for implementation,

and then ‘‘went live’’ on day 3 of week 3. The day before

going ‘‘live’’ we brought in a ‘‘SWAT’’ team of 11 people

so we could start with an empty emergency department.

The results of this change have exceeded our wildest

expectations. Our LOS now averages 2.33 hours, our LWBS

rate is 0.005% and our patient satisfaction is 85.3% and

increasing every month. We used to have 3 waiting rooms;

now most of the time at least one of them is empty. And

all this occurred despite having a 25% increase in census

(with the same number of staff) since the implementation.

—Noreen Vanca, RN, BSN, Administrative Director, Sun

Health Del E Webb Memorial Hospital, Sun City West, Ariz;

E-mail: [email protected]

Answer 2:

We still do RN-only triage in the main emergency de-

partment but use a physician/RN team in the less acute

treatment area (patients with Emergency Severity Index

levels 4 and 5). The patient is seen by the physician/RN

team to avoid duplication of history taking and physical

assessment, as well as allowing immediate awareness of the

orders. The RN performs the phlebotomy.

If only a laboratory test is required for a diagnostic

work-up, the patient goes to a waiting area until the results

436 J

are available. The results and treatment are discussed with

the patient in the physician consultation room, and the

patient then moves to the discharge area for the nurse-

provided discharge instructions and any remaining infor-

mation/paperwork.

Treatment room availability has improved by using the

team and having these relatively nonurgent patients move

throughout the ED visit. Our wait and throughput times,

as well as our patient satisfaction scores, have improved.

—Barbara Simmons, BA, RN, Emergency Department Clini-

cal Educator, Shawnee Mission Medical Center, Merriam, Ks;


SAME LEVEL OF CARE FOR ADMITTED ED ‘‘HOLDS’’

How are other emergency departments meeting the

requirement of the Joint Commission on Accreditation of

Healthcare Organizations (JCAHO) to provide the same

level of care and continuity of care for patients admitted

to the hospital but who are ‘‘held’’ in the emergency

department awaiting an available bed (LD 3.15; 3.20)?

Answer 1:

Generally the same standard of care is interpreted as the

same procedures, paperwork, and assessments that the in-

patient normally would receive. Our consultant’s main con-

cern when evaluating our institution for this standard was

that the emergency department had different documen-

tation forms than the inpatient units, which could lead to

a different standard of care.

The hospital decided to use its Meditech electronic

documentation system to help validate the same level of

care with ED ‘‘hold’’ patients. The Meditech medication

administration record is printed for all ED hold patients

so we have the exact same medication list to help ensure

the continuity of drug administration. The emergency de-

partment currently uses computer ‘‘down time’’ printed

versions of the inpatient computer screens for charting.

Once we complete our installation of the electronic ED

medical record in the system, we will change to a com-

puterized version of similar forms.

Whenever possible we use f loat pool or inpatient

nurses (from the ICU/ED float pool for ICU patients)

to care for the ‘‘holds.’’ Our ED nurse-to-patient ratio

OURNAL OF EMERGENCY NURSING 32:5 October 2006

mailto:[email protected]



is 1:4. It is 1:3 for 1 ICU and 2 medical-surgical patients or

1:2 for 2 ICU patients.

We believe that having the same level of charting (con-

tinuity), along with the same or better nurse-to-patient

ratios than the inpatient units, should suffice. We do not

do any telemetry/medical-surgical competencies because

they are fairly integrated into our ED competencies. To

meet ICU competencies, we have a combined ICU/ED

‘‘skills fair’’ yearly to review and validate those similar skills.

The issue we still wrestle with is at what time in the

‘‘hold’’ period to start the switchover to inpatient forms.

—Will Roden, RN, BSN, Director, Emergency Services, Doc-

tors Community Hospital, Lanham, Md; E-mail: wroden@

DCHweb.org

Answer 2:

In addition to initiating the admission orders and medi-

cations, we try to assign all of the ‘‘holding’’ patients to one

area with one nurse to care for them. This way we attempt

to avoid the predicament of making the nurse choose be-

tween meeting the needs of a new emergency or the main-

tenance (but important) needs of the ‘‘hold.’’ If the ‘‘held’’

patients’ needs have been met (eg, scheduled medications

and assessments), the nurse can f loat within the depart-

ment to help out. We also call housekeeping to help us

find actual hospital beds for the patients to use because

they are much softer than the ED stretchers. Using beds

helps prevent skin breakdown and patient complaints.

—Kim Morgan, RN, MSN, CEN, Charge Nurse, Charles-

ton Area Medical Center, General Division, Charleston, WV;


Answer 3:

JCAHO surveyors told us that they expect the emergency

department to complete the full admission assessment

within the time frames stated in our assessment policy. I

am proposing an admission assessment time frame change

from ‘‘begin in 2 [hours], finish in 8 hours’’ to a policy that

would allow the assessment to be completed within the

first 24 hours of admission. This allows an admission team

or nurse to finish the paperwork during normal operating

hours (eg, 9 am to 9 pm). Many of the inpatient assess-

ment forms (eg, Braden Scale for skin breakdown risk and

discharge needs) take considerable time to complete but

do not provide any additional information needed for

the care that will be provided while the patient is in the

October 2006 32:5

emergency department. A short shift assessment would

cover the skin, falls, and all other JCAHO-required ED

assessment foci.—Shawn Zimmer, RN, CEN, BSOM, ED

Clinical Supervisor, Northwest Medical Center–Springdale,

Northwest, Ark; E-mail: [email protected]

DETERMINING THE NUMBER OF NEEDED ED BEDS

How do other managers figure out what number of patient

beds are needed in the emergency department to handle

their census?

Answer 1:

I use a formula presented by the Veterans Health Ad-

ministration that uses a baseline of a 10% ED admission

rate and 2250 patients per bed per year. The number of

patient visits per bed is then adjusted up or down by

50 patients per percentage point in the admission rate.

For example, a 15% admission rate would translate to

2000 visits per bed per year. A 1% increase in admission

rate to 16% would lower the number of visits per bed to

1950 per year.

Multiply the number of patients per bed by the total

number of ED beds to get an estimate of the maximum

number of patient visits your emergency department can

handle comfortably. For example, a 20-bed emergency de-

partment with a 15% admission rate would be able to

handle a maximum of 40,000 visits a year adequately

(20 beds � 2000 patients per bed). Exceeding this num-

ber by too much can cause the department to operate

inefficiently and potentially lose revenue. Using this for-

mula in our presentations to the hospital executive team

helped us make a case for 2 recent expansions of our

emergency department.—Mark Liwoch, MS, RN, CEN,

Administrative Director, Emergency Department, Shore

Memorial Hospital, Somers Point, NJ; E-mail: milwoch@

shorememorial.org

Answer 2:

We looked not only at our admission rate but at our over-

all patient acuity. I have seen a range of 1500 to 2000 pa-

tients per bed per year. We use 1750 annual patient visits

per bed per year. We have a 30% admission rate and,

similar to what is happening across the nation, there is a

significant ‘‘boarder’’ problem. I have found that planning








on 2750 patients per bed per year allows us some wiggle

room.—Mel Stibal, RN, BSHC, Administrative Director,

Emergency/Trauma Services, Memorial Regional Hospital,

Hollywood, Fla; E-mail: [email protected]

Answer 3:

According to the standards of the Academy of Industrial

Architects (AIA), a ballpark figure in design is 1800 pa-

tient visits per ED bed per year. If your emergency de-

partment has a high number of boarding patients, then

use 1500 visits per bed. This number is an industry norm

that I have found valid in the many times I have used it

with my consulting work.—Christina D. Coad, RN, MSN,

MSM, CEN, Stellar Outcomes Consulting, Columbia, Md;


Answer 4:

The American College of Emergency Physicians has a pub-

lication, Emergency Department Design: A Practical Guide to

Planning for the Future, by Jon Huddy, AIA, that includes

parameters for a facility to consider. This helps the facility

to determine if it is a ‘‘low range’’ or ‘‘high range’’ user of

beds related to the departments’ annual visits. Some of the

parameters include the percent of nonurgent versus urgent

patient presentations, imaging services in the emergency

department, the average LOS in the emergency depart-

ment, and turnaround time for diagnostic tests. Also, the

estimated number of observation/clinical decision beds is

addressed.—Margaret Montgomery, RN, MSN, Practice

Management Manager, American College of Emergency Phy-

sicians, Dallas, Tex; E-mail: [email protected]

ABDOMINAL PAIN TRIAGE PROTOCOLS

What are other emergency departments using as triage

protocols or standing orders for patients with

abdominal pain?

Answer 1:

Our triage protocols are based on the JCAHO Standards

PC.3.230 and PC 5.10 and ENA Standards I-VIII. The

nurse initiates the orders when the patient presents to

the emergency department with a complaint of abdomi-

nal pain. The ED physician is notified of the patient

arrival, results, and abnormalities. The nurse writes the

438 J

orders on the physician order sheet for the ED physician

to sign.

Our abdominal pain triage protocol includes:. assigning the patient nothing by mouth (NPO)

status.. initiating an intravenous line with 0.9% normal sa-

line solution at 1000 mL/hour.. obtaining a urinalysis and a urine pregnancy test for

women of child-bearing age who have not had a

hysterectomy.. drawing blood for a complete blood cell count (CBC)

with differential, electrolytes, and amylase/lipase levels.

If the patient has vaginal bleeding or is having a mis-

carriage, a urine specimen is obtained by a straight cathe-

terization and the nurse orders a urine human chorionic

gonadotropin (HCG) level. Additional blood work that is

held includes a type and screen and pregnancy laboratory

tests (if these were not done earlier). Another source of

triage protocols is found at the following Web site: http://

www.nurseeducation.org.—Pam Wellman, RN, ED Nurse

Manager, Albert Lindley Lee Memorial Hospital, Fulton, NY;


Answer 2:

Our triage protocols are termed Advanced Nursing Inter-

ventions. For patients with upper abdominal pain, they in-

clude the following:. Sending blood samples for a CBC, electrolytes, li-

pase level, and pregnancy test on all premenopausal

women. Inserting a saline lock. Obtaining an EKG if the patient is older than

30 years

For patients with lower abdominal pain and/or vaginal

bleeding, they include obtaining samples for the following:. CBC and urinalysis. Serum qualitative pregnancy test on all premeno-

pausal women if the pregnancy status is unknown. Beta HCG if the patient is known to be less than

16 weeks pregnant by dates. Group and Rh if the patient has vaginal bleeding and

is suspected to be pregnant

We also obtain fetal heart tones if the fetus’ gestational

age is greater than 12 weeks. The protocols have worked








http://www.nurseeducation.org




well for us in enhancing our patient f low.—Melinda Stibal,

RN, BSHC, Administrative Director, Emergency/Trauma

Services, Memorial Regional Hospital, Hollywood, Fla; E-

mail: [email protected]

Answer 3:

Our policy requires that the nurse’s assessment includes

(but is not limited to) the following:. PQRST assessment of the pain. Presence of nausea, vomiting, and/or diarrhea. The last bowel movement and last menstrual period

(for women of childbearing age). Pertinent history of kidney stones or gastrointestinal

disorders. Hydration status and orthostatic vital signs, as needed. Presence of bowel sounds

The nurse initiates the following procedures:. Obtains blood for a CBC, electrolytes, and amylase,

and urine for a urinalysis and urine pregnancy test

(if the patient is a female of child-bearing age). Inserts a saline well (ie, intravenous line). Infuses 0.9% normal saline solution if the patient is

orthostatic, as directed by the physician. Keeps the patient on NPO status. Prepares the patient by placing them in a patient

gown, putting women of child-bearing age on a pelvic

stretcher, and prepares supplies for other diagnostic

procedures, such as the hemoccult slide and developer

—Conni Tucker, RN, CEN, AEMT-P, ED Supervisor, Glens

Falls Hospital, Glens Falls, NY; E-mail: [email protected]

Answer 4:

Our protocol is for upper, persistent abdominal pain in

patients of either sex.

If the patient is more than 35 years of age, we obtain

the following:. EKG, electrolytes, CBC, liver panel, lipase. Dip urinalysis. Kidneys and upper bladder (KUB) f lat and upright

radiographs if the patient is vomiting and has not

had a bowel movement for 12 to 24 hours

For low abdominal pain in males of any age, we obtain

the following:. CBC. Dip urinalysis plus a microscopic examination if the

dip result is positive

October 2006 32:5

. KUB flat and upright radiographs if the patient is

vomiting and has not had a bowel movement for 12

to 24 hours

For low abdominal pain in menstruating females of

any age, we obtain the following:. CBC, HCG. Catheterize the patient for a urine sample to perform

a dip urinalysis plus a microscopic examination if the

dip result is positive

—Kevin Trainor, RN, CEN, ED/Trauma Nurse Manager,

Christus Santa Rose Hospital, San Antonio, Tex; E-mail:

[email protected]

HOURS PER PATIENT VISIT

It’s budget time. What hours per patient visit (HPPV) values

are other departments using?

Answer 1:

Our emergency department has 39,000 patient visits per

year. We use 1.94 worked hours per visit and 2.09 hours

per visit of worked and nonproductive time.—Beth

Yandell, RN, Director, Emergency Department, Conway

Regional Health System, Conway, Ark; E-mail: byandell@

conwayregional.org

Answer 2:

We conduct an annual survey of hospitals to learn about

demographic and operating trends in nurse staffing. These

data have become a national benchmark for nursing de-

partments across the United States. In our latest study, our

120 responding hospitals classified themselves as teaching

(38%), community (51%), and rural (11%).

For ED patients, we found that the average HPPV

was 2.26, with the largest number of hours being 2.5 to

3.1 (41%). The range was from 0.6 to 4.6 HPPV, with the

mid range being 2.3 to 3. The highest average HPPV was

in teaching hospitals (average 3 HPPV), then community

hospitals at 2.7, with rural hospitals averaging 2.4 HPPV.

The indirect HPPV was 0.5, with the range being

from 0 to 1.9 (mid range 0.8-1.1). The complete report

can be purchased thorough www.lminstitute.com or by

calling 602-404-7544.1—Carol Ann Cavorous, RN, MS,

CNAA; E-mail: [email protected]; and ChrysMarie

Suby, RN, MS, Labor Management Institute, Phoenix, Ariz









http://www.lminstitute.com

http://www.lminstitute.com




REFERENCE

1. Cavorous CA, Suby C. Results of the 2004 Annual Survey ofHours: part 1. J Clin Systems Manage 2005;7:7-11.

Answer 3:

Instead of using HPPV, I recommend using the ENA

Guidelines for Emergency Department Staffing. HPPV

equates all patients, regardless of acuity or length of stay.

The ENA guidelines utilize not only the volume (‘‘heads in

beds’’), but also the ED length of stay and resource use

(level charges). It allows a more individualized approach

and has provided justification for our current staff and an

investment in incremental full-time equivalents.—Paul D.

Ferrell, RN, MBA, Trover Foundation, Regional Medical

Center; Director, Emergency/Trauma Services, Madisonville,

Ky; E-mail: [email protected]

Answer 4:

I have been using the ENA staffing tool for more than

2 years and believe this tool is essential for all ED man-

agers. Our professional organization has provided us with

an evidenced-based practice tool that allows us to stan-

dardize our approach to staffing on a national level. If

everyone used the tool, we could reduce variation and stan-

dardize staffing methodology across the United States in

a powerful way!

I find the tool helpful in educating the staff on how

we arrive at our staffing patterns. It is very intuitive in

linking documentation and length of stay to acuity that

translates to staffing and skill mix. Sharing the data quar-

terly at the staff meetings also provides education on un-

derstanding f lex budgets and the nonproductive benefit

and education time that is calculated into the formula.

The tool also has helped me to educate senior leader-

ship. It has taken several sessions for them to understand

the ‘‘formula,’’ but it demonstrates clearly the relationship

between LOS and full-time equivalents. Once they under-

stood that, they could understand better how overcrowding

and diversion are about the organization, not just the emer-

gency department.

This tool has provided a common language with the

finance people and quantifies our needs in a consistent

format. It has helped me to build, maintain, monitor, and

moderate appropriate and safe staffing levels. Armed with

these data, the charge nurse group is actively involved

in creating our staffing plan.—Lorna K. Prutzman, RN,

440 J

MSN, Director Emergency Services, University of Colorado

Hospital, Denver, Colo; E-mail: [email protected]

MOBILE VERSUS STATIONARY PATIENT CARE COMPUTERS

We are remodeling and trying to decide whether to plan for

mobile computers on wheels or stationary computers.

Can someone make a recommendation?

Answer:

We have a combination of both stationary and mobile com-

puters. We mounted stationary personal computers high

on the wall, with the keyboards and monitors on an arm

on the wall over the bed. We use our computers on carts in

the hallways and our trauma bay, where space is limited.

We also use wireless tablet personal computers to capture

patients’ signatures electronically.

I would recommend that you not rely on a single

system. We use wireless carts and wired personal com-

puters. This approach provides the f lexibility to have a cart

at the bedside if that stationary computer has a problem

that requires the technology staff (eg, a broken cable).—

DeWayne Siddon, RN, MS, Emergency Services Information

Systems Coordinator, Erlanger Health System, Chattanooga,

Tenn: E-mail: [email protected]

REGISTERED NURSES REMOVING SUTURES

Do other emergency departments allow nurses to remove

patients’ sutures?

Answer 1:

Nurses at Shawnee Mission Medical Center have removed

sutures and/or staples for years. The triage nurse evaluates

the wound, removes the sutures/staples if it is appropriate,

and discharges the patient if the patient was sutured in our

emergency department. The suture removal visit is consid-

ered an extension of the plan of care for the patient’s orig-

inal visit. Documentation is added to the existing record

rather than generating a new chart. There is no additional

charge for this visit.

If the patient has any signs of infection or poor wound

healing, or if the patient asks to see a physician, then the

person is registered just as any other patient would be and









is evaluated by the ED physician.—Barbara Simmons, BA,

RN, Emergency Department Clinical Educator, Shawnee Mis-

sion Medical Center, Merriam, Ks; E-mail: Barbara.simmons@

shawneemission.org

Answer 2:

The ED nurses routinely assess and remove sutures. We

have a sticker we place on the front of the chart that has a

series of questions with check-off answers that facilitates

the process. Before removing the sutures, the nurse eval-

uates and documents the following information:. ‘‘Does the patient verbalize complaints?’’. ‘‘Does the patient appear in any acute distress?’’. ‘‘Is the patient febrile?’’. ‘‘Any objective evidence of infection? Wound dehis-

cence?’’

If the answer to any of these questions is ‘‘yes,’’ or if

the nurse questions the removal (eg, not a long enough

period has elapsed since the wound was sutured), then the

patient is evaluated by the ED physician.

The nurse documents the remainder of the informa-

tion requested on the sticker. This includes the following:. Date sutured. Location sutured. Date patient was told to have the sutures removed. Number of sutures placed. Number of sutures removed. Complications (eg, bleeding)?. Dressing or steri-strips applied

We have been doing this for years, and it works well

for us.—Wendy Nivison, RN, BSN, CEN, Per Diem Staff

Nurse, Maine General Medical Center, Waterville, Maine;


Answer 3:

All of our fast-track nurses and nursing technicians main-

tain competence in suture removal. An RN must evaluate

the wound to validate that it fits specific criteria (eg, it

must look well-healed). The nursing technician can remove

the sutures once the RN (or physician assistant) has as-

sessed it. Also, the RN must discharge the patient.

We do not charge for these visits. If we did, then we

would need to have a nurse practitioner, physician as-

sistant, or physician see the patient.—Robert G. Flade, RN,

BS, Director, Emergency Department, New Britain General

Hospital, New Britain, Conn; E-mail: [email protected]

October 2006 32:5

SELECTING AN EDIS

What should I consider when making the decision about

what Emergency Department Information System (EDIS)

to buy for our new emergency department?

Answer:

I recommend that all managers should know 3 things re-

lated to choosing an EDIS. These are:. Decide what you want the EDIS to do for you.. Make the decision jointly with your information

technologies (IT) staff, considering the specific needs

of your department, the existing IT technology at

your facility, and your budgetary limits.
. Verify everything. When a vendor tells you that a
certain system works well with your existing IT sys-

tems or performs a certain function, get references

and check them out diligently.

—DeWayne Siddon, RN, MS, Emergency Services Informa-

tion Systems Coordinator, Erlanger Health System, Chatta-

nooga, Tenn: E-mail: [email protected]









Documents

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care