Nursing approach for decreasing critical care time in the ED
Heather Lechner, BSN, RN, CEN
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Purpose: Critical care continues to be a growing proportion of emergency medicine. These patients contribute to increased EDLOS and overcrowding, both of which have well documented negative consequences for patients, staff, and hospitals. This project was designed to decrease the time from bed assignment to ED disposition of critical care patients.
Design: This evidence based project addresses quality and safety, patient experience, employee engagement, and efficiency/productivity. It was designed by a multi-departmental nursing team. Setting: This project was completed in a 457 bed, regional acute care facility. It is a tertiary referral, level 3 trauma center.
Participants/ Subjects: The project was piloted by all nurses from the ED and our two largest ICUs, and included all patients admitted to those units.
Methods: A multi-departmental nursing team identified opportunities for improving the timely transfer of patients awaiting admission by improving the information and process of hand-off, and changing the process of critical care transport. Due to the high volume and acuity of our ED, it was difficult to leave the department for the 25-30 minutes it required to transport the patient to the ICU and give report. A process map was designed for a pilot where the ICU nurse who had a clean, ready, room would use the LEAN concept of "pull", and within 30 minutes of bed assignment, come to the ED, obtain bedside report, and transport the patient to ICU. Nurses involved in developing pilot completed shadow experiences. A pre and post pilot survey was sent to obtain subjective data on the process, quality, and safety of handoff. Weekly phone conferences, and monthly face to face meetings were held to evaluate progress.
Results/Outcomes: There has been a decrease in the amount of time from "decision to admit" to "disposition from the emergency department" by approximately 30 minutes. (Due to the report capabilities of previous software, bed assignment to ED disposition was unable to be tracked.) There was an improvement in nurses' perceptions regarding hand-off by approximately 1 point on a 5 point Likert scale for each survey qestion. During the pilot, ED scores were the highest they had ever been. Employee engagement scores on both units improved, particularly on questions that addressed interdepartmental communication. Ongoing data collection will determine if trends are seasonal.
Implications: Transport of critically ill patients to the ICU by the inpatient nurse may reduce critical care time in the ED, a well evidenced measure to improve the quality and safety of patient outcomes. Although there was an improvement in nurses' perceptions regarding hand-off, the literature supports standardization of a framework to guide the information communicated. There has been an overall improvement in understanding the goals of our fellow teammates, and an appreciation for the challenges their particular unit presents. Inter-departmental shadow experiences during orientation would prove to be valuable in understanding the "why behind the what," preventing silos, and fostering teammate engagement.
Emergency Nursing 2018. Held at David L. Lawrence Convention Center, Pittsburgh, Pennsylvania, USA
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