No Waiting Room, No Wait? A New ED Model at Washington's Swedish Medical Center
Swedish Medical Center's Issaquah campus completed phase one of construction and opened the ED, among other areas, in July. The department was designed to accommodate a streamlined process of treating patients in the ED, a model that began in the Issaquah freestanding ED in 2005. For example, there is no formal waiting room, forcing physicians and staff to get patients in exam rooms immediately upon arrival. "Patient satisfaction and patient safety were the driving force [behind] why we're pushing to have a no-wait philosophy in the emergency department," Dr. Milne says. Long ED wait times are a source of frustration for many patients; eliminating this wait period would boost patient satisfaction while also minimizing the time between a patient's arrival and examination.
When a patient enters the facility, he or she is greeted by a front desk staff member who asks the patient if he or she is there for the ED. If no, the staff member directs the patient to another area; if yes, the greeter notifies the clinical team and brings the patient into a treatment room. Once in the room, a team of ED physicians, nurses and staff members attend to the patient, taking vital signs, situating the patient in bed and attaining the patient's information. Dr. Milne likens the process to a NASCAR pit crew fixing a racecar, in which a team works together to quickly achieve their goal. "The idea is that the patient doesn't spend any more time [in the ED] than absolutely necessary. Get in and get back out again without sacrificing quality of care," he says.
Each team member has specific duties, according to Dr. Milne. The primary nurse is responsible for tracking the patient throughout his or her care in the ED, whereas the technician takes the blood pressure and other vital signs. The physician evaluates the patient's condition and provides direct care. "Interventions, when needed, are immediately provided, not triaged," Dr. Milne says. "Within the first 15 minutes, X-rays are ordered, labs are ordered, the patient is seen by the physician and care has been initiated."
The charge nurse monitors the entire ED, visually assessing each patient quickly when he or she arrives and ensuring exam rooms are open for incoming ED patients. Maintaining available rooms can be challenging, but the ED has kept to its promise of "no wait" 99.9 percent of the time, Dr. Milne says. For example, the charge nurse may need to move a patient to a discharge holding area to complete treatment while a new patient is brought into the room. The physician also has a responsibility to keep exam rooms open by prioritizing patients. Dr. Milne prioritizes patients based on the seriousness of the case: For more complex cases, he checks in with the charge nurse and orders labs or images for the patient. While those are running, he attends to simpler cases, such as an ear ache or sprained ankle. Only then does he perform a complete history and physical exam of the patient with the complex case. "Complex patients can take a lot of time and need me to really dedicate my attention to them. Unless they are unstable for some reason, that sicker patient is going to be there for a little while," he says. "My goal is to not let the simple cases back up."
The no-wait ED has achieved many of its goals so far: Patient satisfaction is greater than 95 percent, according to Press Ganey, which this year awarded the Issaquah ED its third consecutive Press Ganey Summit award — the highest recognition for sustained customer satisfaction. The ED also scored highly on core safety measures such as antibiotic start time and EKG orders. However, success has not come easily. One of the challenges is ensuring appropriate staffing ratios — about 1:3 or 1:4 according to Dr. Milne — and getting nurses comfortable with asking for help. "People don't want to be seen as being weak by their colleagues because they have to ask someone to help. [They need to] get used to the concept that we take care of patients together as a team. It's not your job or my job, it's our patient and our job," Dr. Milne says. "That kind of process is a foreign concept for [many] nurses who may have worked in other environments."
Getting staff and physicians accustomed to the new ED culture is one of the biggest challenges, but also one of the biggest factors in success in this initiative, Dr. Milne says. "I can't overemphasize enough the role that culture plays in making this work. There has to be true buy-in from staff and physicians to be able to say, "I want to create a unique patient experience here.' It starts at the top, and requires clear vision and leadership and a willingness to recognize that not everybody is going to fit in that environment," he says.
To build the collaborative, patient-centered culture in the ED, staff and physicians participate in a three-day cultural immersion program where they learn teambuilding by practicing cases in a simulation center. Afterwards, a skills development program continues to emphasize the importance of working caring for the patient as a team.
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