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Immediate Bedding

'Immediate bedding' boosts patient satisfaction at California emergency department

Performance Improvement Advisor
December 2003

For sick or injured patients, the average wait of nearly an hour to see a physician at Good Samaritan Hospital's emergency department in San Jose, CA, must have seemed like an eternity. Many expressed their frustration on patient satisfaction surveys, giving the emergency department low marks.

But since Good Samaritan instituted a practice known as "immediate bedding" in its emergency department, unhappy patients have almost disappeared and its patient satisfaction ratings have skyrocketed.

Instead of sitting in chairs in the waiting room, newly arrived patients are now brought back into the treatment area and placed in a bed, provided one is available. Not only are patients more comfortable, but the change has allowed physicians to see them much sooner. The average time it takes to see a physician or physician assistant has dropped to less than 29 minutes.

The change came about after Good Samaritan's emergency department was renovated and expanded, explains Ellis Weeker, MD, regional director of the California Emergency Physicians Medical Group, which staffs the hospital's ED. The facility had been upgraded, but patients' long waits persisted. "We realized that we needed to look at all of the systems and how to improve, not only how we took care of patients but how we related to other parts of the hospital," he says.

A process improvement committee met several times a month to develop solutions. "We looked at every aspect of how we managed patients, and we identified areas where there were bottlenecks and we were able to look at other facilities around the country and come up with modifications or our own innovations to institute changes," says Weeker.

The team worked closely with Good Samaritan's X-ray, lab, and registration staffs. "Anyone who would collaborate with us, we brought them into the process," he says.

To get a handle on the problem, they measured the average time from when a patient walks in the emergency room door until he or she sees a doctor or a physician assistant. Before the project started, it took about 56 minutes for a patient to see a provider. "That was one of our really important goals, to reduce that time," says Weeker. The team also looked at the total time patients spent in the emergency department, and how quickly lab tests or X-rays were available.

It was important for the process improvement committee to gain buy-in from the other departments in the hospital, says Gary Li, MD, medical director of the Good Samaritan ED. "We had a lot of support from all the other departments, as well as our nurse management and the administration. Without all that support and buy-in, we certainly could not have made the improvements that we did."

On the fast track
One of the first things Good Samaritan did was institute a dedicated "fast track" program in an area next to the main emergency department. Instead of pushing non-acute patients to the back of the line for the main ED, the seven-bed fast track area allows people with minor emergencies to be seen and treated much sooner.

The fast-track program plays a crucial role, says Li, as the area handles 25% to 30% of the emergency department's patient load. It has been successful because the hospital has designated nurses, registrars, and technicians to work in the fast track program on a dedicated basis. The physician group has also provided dedicated staffing, with a significant amount of double coverage during the busiest times, such as weekends. "We have worked with the hospital to ensure that it is open the hours that it is supposed to be open," says Li.

Another important factor, says Weeker, was that the fast-track space was included in the emergency department renovation project. "In a lot of emergency departments the fast track is kind of an after-thought, and sometimes it is not even a separate area. Or if it is a separate area, it is very far away from the main department. We feel like we have the ideal design."

The next step was to implement the immediate bedding policy. Rather than making patients go through the steps of registration, triage and assessment before being taken to a bed in the treatment area, "we decided that if we have beds available, why not do everything at once and have them come back immediately," says Li.

Under the new policy, as soon as patients show up in the emergency department waiting area they are given a quick triage to determine whether they should be seen in the fast-track area or the main ED. If there is enough staffing and space availability, the patients are then brought immediately to a bed.

Once the patient is settled in a bed, a physician or physician assistant stops by to begin treatment. This happens at the same time as the patient is being registered at the bedside and nurses are completing necessary assessments.

These processes used to be done in a sequential order, Li notes, but now they happen parallel to each other. "We're compressing all these different things that were once done one at a time," he says. That has significantly sped up the time it takes for the patient to see a physician or physician assistant.

Culture Change
Probably the biggest issue in accomplishing the process improvement was changing the culture of the people who work in the emergency department, say Li and Weeker. Staffers who were accustomed to doing their jobs a certain way were being asked to do things very differently.

"Just explaining and convincing and getting support is your first bridge to cross" when making such a performance improvement, says Weeker.

Registration staff who were used to sitting at desks were now being asked to talk to patients in their rooms, either typing information into a bedside computer terminal or taking it down on a clipboard and then entering it at one of two satellite registration desks in the treatment area.

Nurses who work in the treatment area had grown used to having the triage nurse out front complete a long nursing assessment, which contains elements required by various regulatory agencies, says Li. But making the sole triage nurse complete all that paperwork was backing up the flow of patients in the waiting room, he says. So a culture change was needed to convince the nurses in the treatment area to take on the job of completing the documentation.

Part of the process involved getting nurse leaders to work on the new policy with the physicians, Li says, so that there was buy-in from everyone.

It was important to get the nurses to see triage as a function, not a place, says Weeker. What had happened over time was the nurses triage became a small room near the waiting area that all patients had to pass through to fill out a lot of forms. "That was where the bottleneck was. Once we said, 'no, triage is sorting and deciding which room they should go into,' many patients are simply met at the door and don't ever go to that room called triage."

"It is not just a change of culture for registrars and for nursing. It's also a change for the physicians as well," says Li. Physicians were accustomed to using triage as a valve, closing off the flow if the emergency department was busy, he explains. With the immediate bedding policy in place, they would no longer have the ability to make patients sit in the waiting room until they got caught up. Instead, they would need to take the attitude that if a patient was in a room, he or she needed to be seen immediately.

To make the change successful, Li says the California Emergency Physicians Medical Group made sure the emergency department was adequately staffed to handle the patient flow. The physicians on the staff adopted a policy that they would come in early if needed and stay as late as necessary to take care of the patients.

Delighting patients
Replacing the sequential process with a parallel process means that many steps are initiated simultaneously, says Weeker. For example, a nurse may be taking the patient's vital signs at the same time the registrar is gathering insurance information.

It might seem like this would be chaotic, but the staff has learned to work together so that everything goes smoothly, the physicians report. The result has been a time-to-doctor that is much below the national average, says Weeker. "Sometimes it is 17 to 20 minutes, depending upon how sick the person might be. That's such a surprise and actually shock for a lot of patients to be brought back (to a treatment bed) that quickly," he says.

Good Samaritan's 25 emergency beds do occasionally fill up, but patients have to sit in the waiting room only 5% to 10% of the time, Weeker estimates. The backlog is kept at a minimum now because patients see a doctor faster, which means they get their lab tests and X-rays much sooner, he explains.

"If you can see people more quickly and you can get them out more quickly, then we actually have more available bed usage," says Weeker. "We actually get more use out of our beds this way than if we did it the old-fashioned way."

The performance improvement has been very noticeable to patients, judging by the big increase in patient satisfaction scores. In 2001, the hospital's emergency department was in the 20th percentile among facilities in the HCA patient satisfaction survey. By early 2003, that had improved to the 88th percentile. Good Samaritan ranked in the top three in its peer group on a California Emergency Physicians patient satisfaction survey in early 2003.

"It went up as soon as we made the improvements and it's stayed up," says Weeker of the satisfaction rankings. "We get lots and lots of praise from patients. People are happier, which makes everyone working in the department feel good."