Bridging Orders and a Dedicated Admission Nurse Decreases Emergency Department Turnaround Times While Increasing Patient Satisfaction

Abstract

Although many solutions to the problem of emergency department (ED) crowding have been proposed, there are few data on the use of an expedited admissions protocol (EAP) to decrease ED turnaround times. We performed a before-and-after study to determine whether the institution of a protocol utilizing bridging orders and a dedicated patient admission nurse improved ED turnaround times and measures of patient satisfaction. We conducted the study at a community teaching hospital with an ED census of 55,000 and a Level I Trauma designation. Patients are seen by board certified ED attendings, emergency medicine residents and off service residents; there are no mid-level providers. Patients are admitted to both teaching and nonteaching services. The expedited admissions protocol was instituted over a 3-week period, being fully in effect by January 2006. The protocol mandated that all stable admitted patients (as determined by the ED attending physician) have bridging orders given to the ED nurse by phone without the patient being seen by the admitting physician or resident team in the ED. These 11 preprinted orders specify only the basic orders needed for interim care (including immediate medication needs) and patient safety. After receiving the bridging orders, a dedicated nurse (available 24 hours per day and without clinical responsibilities) locates an available bed; the patient is transported without further physician intervention. We evaluated turnaround times, Press Ganey scores, and number of patients who left without being seen both before (January-March 2005) and after (January-March 2006) institution of the EAP protocol. There were no changes in ED staffing or number of ED or inpatient beds. Turnaround times (minutes) for all categories of patients decreased significantly (p<.005) over the study period: all patients: 223 to 174, mean difference 30.26, 95% confidence interval [CI]: 20.46-40.06; discharged patients: 181 to 154, mean difference 26.94, 95% CI: 18.08-35.81; admitted patients: 350 – 240, mean difference 110.60, 95% CI: 89.08-132.12; fast track patients: 136 −106, mean difference 48.48, 95% CI: 37.78-59.20 (Figure). Press Ganey “Overall ED Patient Satisfaction” scores showed a clinically and statistically significant improvement (78.1 versus 82.1; mean difference: 4.0, 95%; CI: 3.59-4.41.). The absolute number of patients who left without being seen decreased from 281 to 190, although this did not reach statistical significance (0.8%, 95% CI=−1.5 to 3.0%), despite an increase in ED census of 10.2%. Although our interventions were specifically targeted toward admitted patients, it is not surprising that turnaround times for all patient categories improved. Clearly, acute care patients who were ultimately discharged could be seen more expeditiously as turnaround times for admitted patients decreased. We believe the turnaround times for fast track patients declined because the acute and fast track areas are not physically separate in our department, allowing for flexibility in both bed assignments and staffing between the 2 areas. As admitted acute patients moved through the department more quickly, there were more beds and staff available for the fast track area of the department. In hospitals where the acute and fast track areas are completely separate and staffing is not flexible between the 2, similar improvements in fast track patient turnaround times may not be seen. Although much has been written about ED crowding, there are few studies which suggest solutions to the problem.1Chan T.C. Killeen J.P. Kelly D. Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, lengths of stay, and rate of left without being seen.Ann Emerg Med. 2005; 46: 491-497Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar, 2Gorelick M.H. Yen K. Yun H.J. The effect of in-room registration on emergency department length of stay.Ann Emerg Med. 2005; 45: 128-133Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar In 2003 JCAHO called on hospitals to incorporate solutions to ED crowding into performance improvement activities.3Institute of Medicine to overwhelmed ED managers: ‘you’re not alone’.ED Manag. 2006; 187: 73-75Google Scholar The Institute of Medicine states that although forces beyond the department impact operations, the solution may lie in system design and communication improvements.4American College of Emergency Physicians. Fact sheet on ambulance diversion and ED crowding. Available at: http://www.acep.org/webportal/PatientsConsumers/critissues/overcrowding/FactSheetAmbulanceDiversionandEDOvercrowding. Accessed January 1, 2007.Google Scholar The American College of Emergency Physicians has called for further monitoring and data collection efforts to analyze the problem in order to find effective solutions.5Yancer D.A. Foshee D. Cole H. et al.Managing capacity to reduce emergency department overcrowding and ambulance diversions.Jt Comm J Qual Patient Saf. 2006; 32: 239-245PubMed Scopus (42) Google Scholar As the causes of ED crowding are complex, it is unlikely the problem will be resolved with systems improvements alone. However, the process improvements in the current study decreased ED turnaround times during a period of increasing census and improved patient satisfaction. These results suggest a partial solution may lie in process improvements within our own departments.