Last week we discussed the biggest benefits of teamwork in the ED. Chief among them was improved efficiency and increased throughput. This week we'll explore the processes that have helped foster a culture of teamwork at Vituity's EDs. Our experience suggests they can work for almost any type of department and hospital.
In the past, most EDs used a linear flow process. After triage, most patients returned to the ED to wait. Only after they were bedded would they receive a diagnostic evaluation from a provider. From that point on, all tests and treatments occurred at the bedside.
However, with the number of ED visits at an all-time high, most EDs no longer have the capacity to bed every patient. The wait for a bed has become a major bottleneck that contributes to crowding and patient dissatisfaction.
About a decade ago, Vituity EDs began pioneering a split-flow process that evolved into Rapid Medical Evaluation, or RME. This process challenges the conventional wisdom that diagnosis and treatment must wait for a bed and greatly expedites the care of less-acute patients.
RME is driven by an advanced provider-nurse team who work together to triage patients and immediately initiate orders. From triage, patient flow splits into two tracks:
RME departments create decentralized spaces where lower-acuity patients undergo further assessment, have blood drawn for lab work, receive treatment, and meet with the care team prior to discharge. Between tasks, patients return to the waiting room. This efficient use of space allows the team to care for a large number of patients without sacrificing a single ED bed.
Vituity EDs that adopt RME reduce time-to-provider by an average of 30 minutes and improve capacity by 22 percent. The process has been refined over the years at hospitals across the country and has proven effective for EDs of all sizes.
This variation of RME adds a physician to the advanced provider-nurse team in triage:
This variation is especially effective at reducing length-of-stay for moderate-acuity patients, who have historically waited longest in the ED.
During this process, the patient's entire care team — physician/advanced provider, nurse, tech, and scribe — perform the initial assessment together at the patient's bedside. This includes taking a history and determining a plan of care. Each team member follows a defined role throughout the meeting.
Team Assessment has proven to be a great patient satisfier. Patients see teamwork in action, get their questions answered quickly, and no longer need to repeat their histories to multiple team members.
The process also improves caregiver engagement and satisfaction. This is especially true for nurses, who report improved communication and collegiality with physicians and advanced providers.
This process is based on the belief that team members share responsibility for all patients in the ED. Rather than sticking to rigid patient assignments, caregivers work where they are most needed at the moment. The department functions like a basketball team, with frequent handoffs and assists.
As the name suggests, communication is the heart of this process. Team members use wireless communication systems, phone apps, whiteboards, and other tools to follow each patient's progress and stay on the same page.
Team Communication improves throughput and keeps care moving through crises and surges. Patients like that they are rarely left waiting and can ask any team member for assistance and status updates.
Many ED teams do a great job of caring for patients but struggle to get discharged patients out the door. These delays can be a major sticking point for ED throughput.
Historically, nurses waited on the physician for discharge orders and instructions, then met with the patient to complete the process. If the patient had questions (and the majority did), the nurse would leave to consult with the doctor, then return to relay the answer.
Team Discharge eliminates these back-and-forth communications. Patients are discharged by physician-nurse teams. The patient's physician can work with any nurse to complete the process if the patient's assigned nurse is busy.
In addition to improving throughput, Team Discharge greatly enhances nurse satisfaction. The process treats nurses as knowledgeable professionals, not as messengers relaying instructions.
EDs can further improve their operations by collaborating beyond the department's walls. Here are some examples of Vituity ED teams working with colleagues across the hospital to improve care:
The Team RME champions at Doctors Medical Center, Modesto (Calif.) worked with lab and imaging to create integrated processes that further improve efficiency.
The ED team at Madera Community Hospital (Calif.) created a care card to introduce the hospital medicine team to admitted patients. This fosters a feeling of continuity, even if the admission occurs at night when no hospitalist is on duty. To free up provider time, the ED scribe meets with the patient to go over the card and answer any questions.
ED providers at Saint Agnes Hospital in Baltimore worked with cardiologists at the Heart Failure Center to create an integrated pathway for heart failure patients. The process streamlines care and allows many patients to avoid a hospital admission.
Vituity emergency physicians and anesthesiologists at several health systems follow a clinical pathway to improve pain management and expedite surgery for hip fracture patients.
Teamwork doesn't come naturally to most EDs. Departments must often gain buy-in and nurture a culture of collaboration before these processes can fully take root. Identifying champions and forming a multidisciplinary operations committee can help everyone feel heard and foster ownership of the new processes.
Change is difficult, but in the case of teamwork, it will almost certainly pay off for your hospital and patients. Keep at it, communicate clearly, and be sure to model collaborative behavior in all of your interactions. Your efforts will be worth it.
Originally published on August 7, 2018.