Nurse-Led Single Line Referral Program

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I t is 13:30 on a typical Monday afternoon in

southwest Missouri. Patients and their fam-

ilies occupy the waiting room of the Mercy

Springfield emergency and trauma department,

hoping to be seen as soon as possible. Babies

cry as nervous mothers pat their backs, flu

patients adjust their masks, and jersey-wearing

teens apply ice packs to injured limbs, while

ambulance bays fill with trauma patients, and

the air ambulance helicopter is landing on the

hospital helicopter pad. The ability to meet our

community’s need, in this nationally recog-

nized, 47-bed emergency and trauma depart-

ment, is one that is repeated daily in what can

truly be called Mercy Springfield’s front door.

Mercy Springfield is an 866-bed tertiary referral centerand a part of the rapidly growing Mercy Springfield

Communities. Mercy Springfield Communities includes fiveregional hospitals in Missouri and Arkansas, and MercyClinic, a 500-plus physician clinic with 70 locations through-out the region. Mercy Springfield is recognized for its level 1trauma status in the states of Missouri and Arkansas, and itsburn and surgical services. Seventy percent of the admissionsin the hospital come from the emergency department.

In May 2011, our sister hospital, Mercy Joplin (formerly St.John’s), was completely destroyed by an EF 5 tornado. Thisevent served as the testing ground for what would become theSingle Line Referral (SLR) Program. After the tornado, the volumeof inpatients at Mercy Springfield increased by 100 patients perday. Given the continuous regional growth and sustainedincrease in census, it became obvious that our admission, refer-ral, and patient flow processes needed attention.

A comprehensive assessment, performed by the nursingadministration department, examined the current admission,patient flow, and referral processes. Key customers that were

interviewed included local medical staff, hospitalists, and hospi-tal admitting department staff, staff nurses, and the house super-visors. The regional referring physicians, advance practiceprofessionals, and nursing and emergency medical service per-sonnel were also included in the assessment and interviews.

The assessment found:1. Inconsistency in admission practices existed among

admitting providers.2. Mercy Springfield emergency department physicians

received 30 to 40 calls daily from outside referringproviders.

3. The house supervisor served as the funnel for patientplacement and flow 24/7.

Linda J. Knodel, MHA, MSN, NE-BC, CPHQ, FACHE, Kurtis M. Abbey, BSN, MHA, CCRN, Mary Rose Hoff, RN, BSN, and Megan M. Royston, BA

4. The house supervisor also supported nurse staffing andscheduling, acted as evening, night, and weekend shiftproblem solver, and provided emergency support forcodes and rapid response calls.

5. Unit-based managers were not consistently involved inpatient flow issues. Admission and staffing were com-pleted in silos, unit by unit.

6. Unit-based charge nurses were minimally involved withdischarge planning.

7. When local primary care clinic offices were full, thepatients were being directed to the emergency depart-ment for care.

8. Thirty minutes prior to the end-of-day closure, theurgent care clinics would refer those arriving for care,to the emergency department.

9. Regional providers were directed to send their patientsto the Mercy Springfield emergency department.

10. Patients requiring quick results for lab or radiologywere sent to the emergency department versus theoutpatient laboratory or imaging center.

11. The emergency department “left without being seen”rate exceeded benchmarks, and patients requiring areferral were being held at their local facility due tolack of beds in Mercy Springfield.

12. Inpatient beds at Mercy Springfield were unavailableduring certain days of the week and certain times of theday.

13. The inpatient admission, discharge, and transfer ratioswere not being used to ensure optimal staffing needs.

All of these findings impacted the gateway to acute careservices. It was clear that the patient entry process was inneed of a carefully designed, systematic referral and patient

throughput process. A steering committee was developed thatincluded administration, staff nurses, nursing leadership, physi-cian leaders, emergency department physician and staff, clinicadministration, and the leadership of the hospitalist program.

The steering committee developed the following guidingprinciples for the SLR program:

• The program would embody Mercy’s vision: We are thepeople of Mercy Health Ministry. Together, we are pioneering anew model of care. We will relentlessly pursue our goal to gethealth care right. Everywhere and every way that Mercy serves,we will deliver a transformative health experience.

• The program would be coordinated and run by a regis-tered nurse through the nursing administration officeand uphold the Mercy Nurse: Professional PracticeModel.

• The program would include one phone number for allproviders accessing this service.

• The program would be available 24/7. Customer servicewould be pristine.

• The medical staff, led by the hospitalist team, wouldserve as advisors to the SLR program.

• Innovative care delivery models would be developed toassist with inpatient unit and patient flow processes.

• Regular program reports are provided to administrativeand physician leadership.

On the basis of the guiding principles, the staff developedthe program, which included:

• A comprehensive database to store referral data(Figure 1). The database was also developed to incorporate various outcome measures.

• Collaboration with referring providers. Semiannual sur-veys are conducted to assess the level of service and the

August 201336 Nurse Leader

Figure 1. Referral Intake Database This database is filled out for each referral call received and used for trending, follow up, and ongoing monitoring.

level to which the referral provider’s needs are being metby the SLR program.

• Policies, procedures, and an algorithm (Figure 2) toensure practice consistency among the SLR nurses weredeveloped. A register nurse answers the phone within2 rings and assesses to whom the referring providerwould best be connected. For time-critical diagnosessuch as stroke and myocardial infarction, the registerednurse immediately transfers the referring provider to theemergency room physician on call. For all other referrals,the registered nurse pages the appropriate physician, thenremains on the call until the referring and acceptingphysicians complete their dialogue. In the event a directtransfer occurs, a bed number is provided to the refer-ring provider, and the admission process to accept thepatient begins. This triaging process provides appropriateuse of the emergency room services.

• The development of metrics to assess program processes,outcomes, and a customer satisfaction survey.

• Twice daily, unit-based charge nurses attend data-drivenbed meetings to analyze patient flow and staffing needs(Figure 3). Unit-based huddles with providers, therapists,nursing, and case management occur each morning,along with nurse–physician rounding.

• A quarterly program report is provided to the MercySpringfield physician and administrative leadership.

• Marketing tools

Examples of metrics that are used to assist with programmanagement are:

• Number of referrals• The average number of minutes the SLR nurse spends

on each referral• Referral disposition (direct admit, outpatient follow-up,

appropriate emergency room admission). • Referral cycle times

•• Acceptance—elapsed time between referral receivedand physician acceptance

•• Placement—elapsed time between referral receivedand bed assignment

• Lost referrals as a result of lack of available beds In January 2011, Mercy Springfield officially launched the

SLR program. Members of the SLR staff scheduled face-to-face meetings with local and regional referring providers.This included integrated as well as nonintegrated emergencyroom providers, clinic providers, and federally qualified healthcenters. During the visit, the SLR staff provided the referringproviders the policies, metrics, and marketing tools such asphone handset stickers for quick referral dialing.

Data were used to establish hours of operation for theSLR program. Initially, 1.75 full-time equivalent registerednurses were hired to manage this program from 7:00 a.m. to5:00 p.m., 7 days a week. After 5:00 p.m., the on-duty housesupervisor answered the referral line and coordinated referralsand direct admissions.

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Figure 2. Single Line Referral AlgorithmEnsures standardized processes by all SLR nurses. The incoming referral occurs, the SLR nurse answers within 2 rings.Based upon the referral needs, the RN triages the call to the appropriate receiving physician. The referring physician isplaced on hold until the receiving physician returns the call to the SLR nurse. The SLR nurses remains on the line andconnects both providers. At the end of the dialogue, the SLR nurse assists with the outcome of the referral, such asdirect inpatient admission, a phone consult, or an emergency room admission.

During the summer of 2012, only a year into the journey,SLR faced additional challenges and opportunities. Referralvolumes continued to increase after 5 p.m., so metrics andincidental customer feedback provided justification toincrease dedicated SLR nurse coverage to 24/7 (Figure 4).

Our journey has demonstrated exponential SLR growthsince its inception and strengthened relationships internal toMercy Springfield as well as to our referral providers. Theemergency and trauma department volumes have not

decreased as expected, but their appropriateness hasimproved. The number of direct admissions continues toexceed previously set volumes. This growth is the result ofinnovation, business and clinical expertise, and physician andadministrative support (Figure 4).

Today, the SLR team of nurses work out of a new andintentionally designed “air traffic control center.” Using arobust electronic health record, the patient placement staff,the staffing department, and the admitting staff work together

August 201338 Nurse Leader

Figure 3. Daily House ReportThis report is evaluated twice daily to assess resource needs and optimize patient placement, no matter the source.

Figure 4. Volume MetricsSince inception, the numbers of SLR calls and admissions have continued to increase. Medical staff and referringprovider satisfaction are rated 4.5 on a 5-point scale.

to continuously provide the right resource at the right placeat the right time. Our referring provider survey results haveprovided us with suggestions for improvement and a 4.65score, based upon a 1 to 5 scale. Truly, SLR is a nurse-ledprogram, designed to meet the needs of patients within thelocal and regional communities of Mercy Springfield.

At Mercy Springfield, we are continually reaching outin new ways to serve better. We want to make access tohealthcare easier and more personal for the many lives wetouch. We are continually listening to provide care whenand where it’s needed. The mission statement of Mercy isan inspiring reminder of our calling; it also unites anddirects activities across our entire health and human serv-ices ministry. “As the Sisters of Mercy before us, we bring to lifethe healing ministry of Jesus through our compassionate care andexceptional service.” NL

Linda J. Knodel, MHA, MSN, NE-BC, CPHQ, FACHE, is thevice president/chief nursing officer for Mercy SpringfieldCommunities in Springfield, Missouri, and can be reached atlinda.knodel@mercy.net. Kurtis M. Abbey, BSN, MHA,CCRN, is the executive director of nursing, Mary Rose Hoff, RN,BSN, is the single line referral supervisor, and Megan M. Royston,BA, is an education specialist at Mercy Hospital Springfield.

1541-4612/2013/ $ See front matterCopyright 2013 by Mosby Inc.All rights reserved.http://dx.doi.org/10.1016/j.mnl.2013.05.006

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