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More and more people are seeking care in emergency departments, leading to crowding and extended wait times that can adversely affect patient satisfaction and outcomes.
In response, a number of emergency room (ER) nurses have come up with innovative ideas to improve patient throughput and enhance care.
“Wait times are a very prevalent problem,” said Paula Roe, BSN, MBA/HCM, FACHE, senior consultant with Simpler Consulting, based in Pittsburgh, Penn. “There are many things that can be done.”
Roe helps clients discover waste through Lean principles and thereby reduce ER wait times.
How long do ER patients wait?
For the last few years, ProPublica has maintained an interactive news application called ER Wait Watcher, using information from the Centers for Medicare and Medicaid Services (CMS) to educate people about average wait times at emergency departments (EDs).
As of August 2017, ER Wait Watcher reports a national average waiting time of 23 minutes before an ER patient sees a physician.
The state with longest average ER wait time to see a physician is Maryland at 53 minutes, while Utah and Colorado have the shortest average ER wait times at just 13 minutes, according to the site.
ER Wait Watcher charts the time, on average, that patients wait in emergency rooms before:
- They see a doctor;
- They get sent home;
- They’re given pain medications for a broken bone; or
- They are admitted to the hospital.
The site shows state-by-state comparisons and offers details for individual hospitals. Site visitors can also find the closest emergency department and how long it will likely take to get there (using Google’s current traffic information), in addition to how long they will have to wait on average.
What contributes to ER wait times?
The latest fact sheet on ER wait times from the American College of Emergency Physicians (ACEP) reports that a sharp rise in the number of emergency patients in recent years combined with critical shortages throughout the entire emergency medical care system limit everyone’s access to timely emergency care.
Recent ACEP polls have also cited physician shortages in primary care as a contributing factor.
Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, healthcare consultant with Philips Blue Jay and past president of the Emergency Nurses Association, agreed that a lack of primary care contributes to ER crowding and waiting.
She pointed out that patients boarded in the emergency department also stop the flow and lead to crowding. Other people have to wait longer because the ED stretcher is occupied. To solve the problem, Brecher said hospitals must involve the entire hospital in getting patients ready for discharge out, the beds cleaned and the transfers made.
“You have to think of crowding as a hospital problem and not an emergency department problem,” Brecher explained. “It involves an organizational effort.”
Top nursing solutions to reduce ER wait times
Jodi Pahl, chief nursing executive at St. Rita’s Medical Center in Ohio, and the team at St. Rita’s launched a comprehensive communications program to keep all hospital clinicians informed of when patient wait times in the ED increase beyond acceptable levels. Those communications may prompt physicians to discharge patients ready to go home more quickly.
As a result of this program, St. Rita’s was able to decrease patient wait times, as well as walk-out rates. Patients wait to see the doctor an average of 19 minutes at St. Rita’s, according to ER Wait Watcher (data as of August 2017).
Several hospitals have opened fast-track systems to reduce wait time, by getting the “walking well” in and out, Brecher said.
She also reported an increase in the use of provider-nurse teams at the initial point of entry. Tests can be ordered so results are available more quickly once the patient enters the ED. Patients with minor ailments can be treated and released.
Charge nurse Steven Kunz, RN, CEN, of Aria Health’s Torresdale campus emergency department in Northeast Philadelphia, reported that reducing ER wait times and improving care are the key focus areas of the hospital’s emergency department.
“Our strategic group of stakeholders including nurses, physicians and administration, worked together to implement an updated registration system that includes a pivot nurse to help transform triage,” Kunz said.
The pivot nurse greets patients upon their arrival, obtains patient identifiers and vital signs, and performs a rapid assessment to determine the level of need for immediate care.
The pivot nurse concept, combined with an expanded treatment area and more rapid evaluation and disposition by the physician, have worked to reduce wait times and improve patient satisfaction, he added.
Penne Marino, RN, and colleagues at Lancaster General Hospital in Pennsylvania described in the Journal of Emergency Nursing in 2015 how a multidisciplinary team established a Bypass Rapid Assessment Triage process.
Emergency patients are met by a greeter nurse, who conducts a quick assessment to determine acuity and then places the patient in an appropriate bed. This new system reduced the time it took patients to see the physician and enhanced patient satisfaction.
Patients at Lancaster wait an average of 19 minutes before being seen by a doctor, according to the latest statistics on ER Wait Watcher.
The University of Kansas Medical Center (KUMC) in Kansas City, Kansas, hired a bachelor’s-prepared emergency RN as a flow coordinator in hopes of reducing wait times for this busy Level 1 trauma center.
Seamus Murphy, BSN, RN, CEN, CPEN, CTRN, CPHQ, NREMT-P, at KUMC, and colleagues reported in the Journal of Emergency Nursing in 2014 how the flow coordinator decreased length of stay by 87.6 minutes, reduced the number of patients who left without being seen and decreased the number of time the hospital was on diversion.
Where ER nurses can help
Nurses remain on the forefront of trying to improve throughput and reduce ER waiting times. Roe explained that nurses can assess improvements in three areas:
- Triage
- Evaluation by medical staff and associated diagnosis and treatment
- Disposition
“Each phase has its unique opportunities to eliminate barriers, reduce waste and improve wait times,” Roe said.
“Nursing and how nurses deliver care is key in process improvement efforts. It’s important they are involved as frontline staff and part of studying the current state, helping to identify barriers to patient flow and understanding the solutions to deploy to make the situation better.”
