1. DISCLOSURE 1. No planner, presenter, faculty, authors, or content expert has identified a conflict of interest that would affect the educational activities. 2. No commercial interest has provided financial or in-kind support for this educational activity. 3. The Arkansas Nurses Association has provided financial or in- kind support for this educational activity in the form of printing and food costs. 4. Neither ANCC, SCAP, or ARNA endorse any commercial products discussed/displayed in conjunction with this educational activity. South Central Accreditation Program (SCAP) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

2. Emergency Department Patient Flow: A Nurse Driven Improvement Plan Julia Grant, MSN, RN Emergency Department Patient Flow: A Nurse Driven Improvement Plan Julia Grant, MSN, RN

3. Purpose The purpose of the activity is to enable the learner to understand patient flow through the emergency department as well as to describe nurse driven measures for improving patient flow.

4. OBJECTIVES Describe emergency department patiente flow concerns. Explain a nurse driven emergency department implementation plan for improved patient flow Identify ways to maintain effective patient flow through an emergency department.

5. Background Steady increase in emergency department (ED) patient volume and wait times Desire to maintain or decrease costs while improving throughput requires novel approaches to patient flow Institutional, systematic, structural, and seasonal factors contribute to delays and are considered beyond the control of frontline health care workers. (Arya et al., 2013; Cohen et al., 2015)

6. Background How do we decrease length of stay (LOS) in the ED to improve patient satisfaction? o ED overcrowding has caused a decline in patient satisfactions scores How can decreasing LOS in the ED decrease mortality rates? o Example: Starting IV antibiotics early can decrease mortality especially in patients presenting with sepsis and pneumonia How can decreased LOS in the ED decrease healthcare costs? o The development of the Patient Protection and Affordable Care Act 1 has placed increased pressure on healthcare providers to reduce waste and increase efficiency while maintaining and improving the quality of care. (Kane et al., 2015)

7. Welcome to the CAVHS Emergency Department 23 available ED beds for patient care 28,446 ER visits in 2014 5,840 Hospital Admissions in 2014 EDIS Patient Tracking System Two ER nursing teams (A & B) that work cohesively with each other Support staff o Health techs o LPNs o MSA

9. Implemented Nurse First Nurse First pilot began in March 2014 Patient sees triage nurse first upon arrival to ER Nurse First notifies Charge Nurse for patients with ESI Level I or II for immediate bedding Two triage nurses are available to decrease the length of wait time for triage

10. ER Triage Form Changes Previous triage form changed to two-part form in May 2014 Two-part form created in collaboration with CBO decreased duplicate encounters resulting in more accurate workload capture Expedited patient flow by allowing triage and registration to occur simultaneously Facilitates quicker access to triage for the patients

11. Patient Flow Coordinator Collaboration Patient Flow Coordinators conducted Length of Stay analysis in June 2014 Action plan post-analysis o Patient Flow Coordinators began Bed Control/Huddle rounds in ER at 12 p.m. and 4 p.m. each day (July 2014) o Patient Flow Coordinators staffing hours increased to 0700 -2200, M-F with addition of a RN (October 2014) o Added additional 2100 Bed Control Huddle in ER (October 2014) Patient Flow Coordinators collaborate with inpatient units and the ER to increase patient movement o ED Access to BMS NOD / AOD functions as flow coordinator during off tour hours during the weekend and after 10 pm on weekdays

12. ER Admit Length of Stay Source: EDIS

13. Percentage Over Six Hours: Admit vs Total Visits Source: EDIS

14. Customer Service Efforts in the Emergency Department Voice of the Veteran: CAVHS implemented periodical “Quick Cards” to assess our customers’ needs January 2015 Quick Card Results: o Patients were treated with courtesy and respect : Score 9.6/10 o Staff listened to patient : Score 9.6/10 o Patient received sufficient education/information about health care options : Score 9.5/10 o Timeliness of Visit : Score 9.1/10 In December 2014, the “Get ConnectED” brochure was developed to promote ED services and share ancillary resources In January 2015, ED management proposed an action plan to improve customer service for our Veterans, to include lobby services. Lobby Services: o Updated information regarding wait times, departmental flow and provide assistance when needed o Reassess all waiting Veterans and provide them opportunity to ask questions, or be re- triaged on request o Beverage and snack availability to waiting Veterans when not contraindicated o Get ConnectED

15. References Arya, R., Wei, G., McCoy, J.V., Crane, J., Ohman-Strickland, P., & Eisenstein, R.M. (2013). Decreasing length of stay in the emergency department with a split emergency severity index 3 patient flow model. Academic Emergency Medicine, 20(11), 1171-1179. doi: 10.1111/acem.12249 Cohen, R.I., Kennedy, H., Amitrano, B., Dillon, M., Guigui, S. & Kanner, A. (2015). A quality improvement project to decrease emergency department and medical intensive care unit transfer times. Journal of Critical Care. Retrieved from http://vz3uu3pw7q.search.serialssolutions.com/?V=1.0&sid=PubMed:LinkOut&pmid =26365001 http://vz3uu3pw7q.search.serialssolutions.com/?V=1.0&sid=PubMed:LinkOut&pmid =26365001 Kane, M., Chui, K., Rimicci, J., Callagy, P., Hereford, J., Shen, S., Norris, R., & Pickham, D. (2015). Lean manufacturing improves emergency department throughput and patient satisfaction. The Journal of Nursing Administration, 45(9), 429-434. doi: 10.1097/NNA.0000000000000228 McCarthy, M.L., Ding, R., Pines, J.M., & Zeger, S.L. (2011). Comparison of methods for measuring crowding and its effects on length of stay in the emergency department. Society for Academy Emergency Medicine, 18, 1269-1277. doi: 10.1111/j.1553-2712.2011.01232.x Rajapakse, S. (2013). Allied health in-reach in the emergency department: Does it reduce length of stay? The International Journal of Clinical Practice, 67(8), 701-706. doi: 10.1111/ijcp.12192