Streamlining Care

Wash. Hospital Streamlines Emergency Care System

News Nov 09, 2017

Nov. 09—Go to a hospital emergency department, and you’re likely in for a wait.

Wait to be checked in. Wait for a room. Wait for tests. Wait to see a doctor. Wait to be discharged.

And as emergency departments get busier, the waiting times get longer.

At Legacy Salmon Creek Medical Center, the emergency department is busier than ever. In the 2017 fiscal year, which ended in March, the hospital had nearly 74,000 people pass through its emergency department. And the hospital is on pace to surpass that this year. In the first six months of the 2018 fiscal year, nearly 38,600 have sought emergency care at the Salmon Creek hospital.

The increase has the department bursting at the seams—and it’s not alone.

“There’s just hardly any EDs in the nation that aren’t overcrowded,” said Dr. Bill Shawler, a Legacy Salmon Creek emergency department physician.

That reality prompted Legacy Salmon Creek to re-evaluate how its emergency department operates and to make fundamental changes to the way it approaches patient care. Other hospitals had proven that simply increasing the emergency department size wouldn’t solve the problem and could actually make it worse.

“We approached this with the idea that we have to increase our flow, maintain safety and quality but work with what we’ve got,” Shawler said.

This spring, Legacy Salmon Creek implemented a physician-in-triage process and immediately saw improvements.

Traditionally, patients would come into the emergency department, check in at the front desk and wait. A nurse would then bring the patient back to get vitals and more information. And then the patient would sit in the room and wait to be seen by a physician, Shawler said.

Once seen by the provider, there was often more waiting—for labs to be drawn, for X-rays to be ordered and then again for a physician to review those results. Then, for about 80 percent of the emergency department patients, they were discharged, Shawler said.

“As we get busier and busier, those wait times can stretch hours,” he said.

Under the physician-in-triage system, however, that process is more efficient, Shawler said.

Patients still come to the emergency department, check in and are triaged by a nurse. But now, physicians are involved in the triage process, as well, getting patients in front of a doctor right away, Shawler said.

One benefit of that is the physician can order needed labs and images right away, he said. While patients will still have to wait for tests and for the physician to review the results, at least those steps can get started sooner, Shawler said.

“Your care is advancing while you wait,” he said.

Having the physician involved early on can help to move patients with lower-level needs through the ED quicker and get sicker patients admitted to the hospital sooner, Shawler said.

PeaceHealth Southwest Medical Center is implementing changes in its emergency department, as well.

After visiting several emergency departments in the metro area, including Legacy Salmon Creek, PeaceHealth Southwest began testing a new process, called vertical track, with the hopes of moving lower acuity patients—those with lower-level needs—through the ED faster, said Sabrina Coggins, interim nurse manager for the emergency department.

“We do really well with the high acuity,” Coggins said. “We’re focusing on lower acuity.”

“We really want to embrace the lower acuity and make it really efficient so they don’t have to wait,” she added.

The vertical track process is similar to the efforts at Legacy Salmon Creek.

In the vertical track process, lower acuity patients see a physician on the front end and are then moved to an internal waiting area, rather than immediately being assigned a room.

The bottleneck in the ED is always rooms, Coggins said. This process frees up ED rooms for more acute patients and keeps the process moving, Coggins said.

The process will be fully implemented this winter.

PeaceHealth Southwest has also added a new nursing position: patient-flow coordinator. That person monitors all of the charts and fills in where needed. For example, if a patient is waiting to be discharged because their primary nurse is busy, the patient-flow coordinator can step in and complete the paperwork to discharge the patient, Coggins said.

“That’s really significantly shrinking our length of stay,” she said.

Legacy Salmon Creek started testing its physician-in-triage process this spring and, after several trial runs, implemented the system full time in May. The impact was immediate.

In 2016, discharged patients spend about 2 hours 49 minutes in the ED. Since May, the hospital has shaved 15 minutes off of the average length of stay. Providers are also seeing patients an average of 10 minutes sooner.

But the biggest accomplishment, Shawler said, is getting the ambulance diversion time down. When emergency departments are too busy, they divert ambulances to other hospitals. Last year, the Salmon Creek ED was on divert about 25 hours each month. Since May, the hospital is on divert less than 10 hours per month.

“It was pretty amazing right from the get-go,” Shawler said of the process. “It totally changed our ability to handle when we have disasters or multi-months-long disasters that flu season usually is.”

The Columbian, Vancouver, Wash.