Emphasize Teamwork and Communication to Increase Patient Safety

The potential for risk is great in emergency departments. In the hospital setting, EDs rank as high-risk as intensive care units and operating rooms. In all three of those settings, staff members have to work together and communicate clearly to ensure patient safety.

EDs that place a strong emphasis on teamwork, and have in place an effective communication strategy, are able to counteract the inherent risk associated with a patient’s visit to the ED.

Previous studies in health care settings indicate that upwards of 80 percent of medical errors are related to “interpersonal interaction issues,” or more simply, miscommunication. By placing a focus on teamwork and effective communication, an ED will increase not just patient safety, but patient satisfaction, quality of care and staff morale.

Check out these three ways to improve communication and increase teamwork within the emergency department:

1. Implement an Open Door Policy

Effective leaders flatten the hierarchy, create familiarity and make it feel safe to speak up and participate.  — M. Leonard, S. Graham and D. Bonacum

Within EDs, it’s crucial that staff feel comfortable bringing concerns and ideas to their immediate supervisors and those in charge. A sense of strict hierarchy and power structure can discourage your staff from speaking up, but open door policies can counteract those effects and improve communication and enhance teamwork among staff.

2. Standardize Practices

The lack of standardised communication and procedures in medicine increases the importance that team members invest in creating a common mental model; otherwise, there is limited ability to predict and monitor what is supposed to happen. — M. Leonard, S. Graham and D. Bonacum

In many EDs, staff members possess varied levels of experience and responsibility, as well as different personalities and beliefs. To improve communication and foster an environment centered on teamwork among such a diverse group, start by standardizing procedures, practices and communication models. By emphasizing structure within those methods of care, ED staff will all be on the same page and know how and when to communicate concerns or other vital information to their colleagues and those in positions of authority.

3. Be Deliberate

Communication failures are the leading cause of inadvertent patient harm. Analysis of 2,455 sentinel events reported to the Joint Commission for Hospital Accreditation revealed that the primary root cause in over 70% was communication failure. Reflecting the seriousness of these occurrences, approximately 75% of these patients died. — M. Leonard, S. Graham and D. Bonacum

As an ED or hospital leader, when you focus on communication and teamwork, in many instances, you will be changing the culture of your ED. Although the correlation that exists between patient safety and effective communication and teamwork is strong — and benefits, such as improved quality of care and increased patient satisfaction will result — a long-term strategy should be used to implement changes because this type of change takes time and dedication. It’s wise to conduct a deep analysis of every new strategy incorporated, since each step of the process has influence on the overall course of action. Be deliberate and create a schedule with the help of your staff to increase effectiveness.

The positive impact on patient safety, quality of care, patient satisfaction and staff morale that result from improved communication is something I’ve witnessed in many of the EDs Donovan and Partners has had the pleasure of working with. If your ED could benefit from improved communication and enhanced teamwork, feel free to get in touch. Contact Donovan & Partners today at cmd@constancedonovan.com or 651-260-9918. I'd be happy to do a personalized assessment of your ED and provide actionable solutions. For more information on the services we offer, visit our website.

SOURCES:
Nursing Economics: “Measuring teamwork and patient safety attitudes of high-risk areas.”

BMJ Quality and Safety: “The human factor: the critical importance of effective teamwork and communication in providing safe care.”

3 Ways to Lower LWBS Rates in the ED

There can be profound consequences for patients, emergency departments and the healthcare industry as a whole when patients leave an ED before they receive treatment. For patients, delayed treatment can mean sustained illness, pain and even death. For hospitals, high rates of patients leaving without being seen (LWBS) signify a loss of revenue. And for the healthcare industry, when patients seek treatment but don’t receive it, questions regarding appropriate access to care arise.   

The rate at which patients will leave an ED without being seen varies sharply from one hospital to another. In one report published in 2011, researchers looked at patient-visit data from 262 hospitals and found LWBS rates as low as .1 percent and as high as 20.3 percent — a tremendous variation. (The median rate was 2.6 percent.)

The reasons why one hospital may see upwards of one fifth of their patients leave without receiving treatment while another is able to treat almost all of the patients that enter its doors is just as varied. These same researchers offer a few explanations as to why there may be high walkout rates:

• Hospital restructuring and market factors, including the increased number of EDs that have closed their doors.
• The possibility that hospitals in lower-income areas may be closing at a higher rate, causing more vulnerable populations to have less access to care.
• Increased wait times and ED crowding.

It’s important to mention that this study noted hospitals that served a high proportion of low-income and poorly insured patients had disproportionately higher LWBS rates. (Researchers found that the odds of a patient leaving without being seen fell by a factor of .86 for each $10,000 increase in household income.)

With this in mind, what can a hospital do to lower LWBS rates within its ED?

To lower LWBS rates, ED leadership must first identify the reasons why LWBS rates are increasing. Is it because of overcrowding or inefficient patient flow? Did a nearby ED recently close and now you’re seeing an influx of patients? Is your ED properly staffed? Once you identify the causes then you can tailor a plan of action.

Here are a three examples of what EDs have done to curb rising LWBS rates:  

1. Triage is a process, not a location.

In 2011, Illinois’ Elmhurst Hospital moved to a new campus four miles west of its former location. As a result, nearby Gottlieb Memorial Hospital in Melrose Park became the closest hospital for many patients and ambulances in the area. Naturally, due to Elmhurst’s move Gottlieb experienced a surge in average monthly volume — from 1,800 to 2,100 patients — and with that, a 10 percent LWBS rate.

To combat such a high LWBS rate, hospital leaders at Gottlieb implemented a “pull till full model,” redefining triage as a process rather than a location. Nurses were instructed to immediately lead patients to empty rooms and conduct the triage process at bedside. Six months later, Gottlieb’s LWBS rate plummeted to just below four percent thanks to the strategy and other sound initiatives, such as the evaluation of staffing patterns among its nurses and physicians.

2. Communicate with other departments.

In 1999, the ED at Miami Children’s Hospital had a LWBS rate of 5 percent. Its average throughput time was 3.5 hours and patient satisfaction scores were dismal. Over the course of four years, through a series of innovative changes implemented by ED leadership, the ED’s LWBS rate dropped to 1 percent with a nearly one-hour decrease in average throughput time. (Its patient satisfaction scores went from being in the 35th percentile to the 90th percentile.)

How did they do it?

One way was by working with staff from radiology, laboratory, registration and administration to expand capacity and improve flow. By communicating with other departments the ED was able to identify extra space adjacent to their ED to expand into, and then brought on additional physicians and nurses.

They also streamlined the registration process by taking basic information during triage, and pressed hospital leadership to start discharging in-patients in the morning, as opposed to the afternoon. Additionally, housekeeping was requested to clean rooms in a timelier manner.  

3. Keep it simple.

In 2001, Annie T. Sadosty, MD, an attending physician in the department of emergency medicine at Mayo Clinic, and assistant professor at Mayo Medical School, studied the reasons patients leave an ED without being seen. During her research, Sadosty and her colleagues were also able to glean what would cause patients to wait. The results were interesting.

She found that patients would be more likely to wait if they were offered immediate treatment for minor ailments, such as Tylenol for a headache, or ice packs and temporary bandages for injuries. Sadosty also found that by simplyannouncing wait times, patients said they would be more willing to stick around. Providing entertainment for children — think coloring books and toys — would also help, patients told Sadosty.

As you can see, the factors that lead to high LWBS rates are just as varied as the solutions. If you find that your patients are leaving without being seen, Donovan and Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing and patient flow, and then help you implement the best solutions to lower your LWBS rate. Contact us today at cmd@constancedonovan.com or 651-260-9918. For more information on the services we offer, visit our website.

SOURCES:

Renee Y. Hsia, MD, MSc, Steven M. Asch, MD, MPH, Robert E. Weiss, PhD, David Zingmond, MD, PhD, Li-Jung Liang, PhD, Weijuan Han, MS, Heather McCreath, PhD, and Benjamin C. Sun, MD, MPP: “Hospital Determinants of Emergency Department Left Without Being Seen Rates”

GMH ED Staff, Sylwia Wright, RN, MSN, Mark Cichon, DO: “Decreasing Left Without Being Seen”

Urgent Matters: “Reducing the Left Without Being Seen (LWBS) Rate and Throughput Time Miami Children’s Hospital”

Arendt KW, Sadosty AT, Weaver AL, Brent CR, Boie ET: “The left-without-being-seen patients: what would keep them from leaving?”

AHC Media: “Want to drastically cut LWBS numbers? Try ice packs and adding a fast track”

Wait Times: How Does Your ED stack up?

Many patients might look at the emergency department (ED) like they would their neighborhood deli — first come, first serve. Luckily, for critically ill patients, this isn’t the case. The patients who need immediate treatment are going to receive it no matter how many patients are waiting.

Explaining this logic to a patient with a broken finger or a parent with a child experiencing cold symptoms may not be easy. The ED is the last place they want to be, and to them, their pain, or child’s pain, is a priority. Patients sometimes aren’t the best judge of their symptoms, and finding a way to get care outside of the ED can prove difficult depending on the day of the week, time of day and where they live.

The stats seem to reflect that. For example, from 2009 to 2010 more than 25 percent of all ED visits by children were for cold symptoms. For adults 12 percent of visits were deemed non-urgent, for cold symptoms and the like.

But it’s not just more non-urgent patients seeking care that are adding to wait times. With increasing numbers of patients visiting the ED for nonurgent conditions, wait times are bound to spike.

Year after year, average emergency department wait times have increased across the nation because visits are too. More people are seeking treatment at EDs — for urgent and nonurgent conditions — while the number of EDs is decreasing. According to the CDC the number of patient visits to EDs increased 32 percent over a 10-year period from 1999 to 2009. And at the same time many EDs closed their doors due to financial constraints.

So how does your ED’s average wait time compare?

One Measure: Broken Bones

The wait time for treatment of a broken bone is an important measure when it comes to hospital wait times. Of course, there’s different types of breaks and the severity of each will vary, but on average in 2014, a patient had to wait 54 minutes before receiving pain medications upon arrival in the ED.

For a national average, 54 minutes is long and depending on where a patient lives and which hospital they choose for treatment, the wait could have been much longer.

Take Washington, D.C. for example. Emergency departments in urban areas typically have longer wait times. In D.C., patients suffering from a broken bone had to wait an average of 69 minutes before receiving pain meds. This is only 15 minutes more than the national average, but with eight hospitals in the area the wait times varied drastically. If a patient sought treatment for a broken bone in D.C., they may have waited as little as 50 minutes for pain meds, or as long as 150 minutes depending on which ED they chose.

Difference in Wait Times Correlated to Patient Demographics

So who is facing longer wait times besides the no-critical patient? It seems adults go last and the old and the young are put first. According to the Centers for Disease Control and Prevention, Older patients, age 65 and older had the lowest mean ED wait time from 2008-2010 at 48 minutes. Children’s was 51 minutes And, adults 18 to 64 tended to have to wait the longest at 58 minutes.

Researchers found a difference when it comes to gender. Females experienced longer waits than males — four minutes more than men (57 minutes and 53 minutes, respectively).

There were even interesting stats around race. Non-Hispanic black patients experienced the longest wait times (68 minutes), while Hispanic patients waited 60 minutes, and non-Hispanic white patients waited 50 minutes.

What Will the Future Hold When it Comes to Wait Times?

On average they’ll increase, but there’s no reason your ED can’t be an outlier. First, you need to know where you stack up, which you can do by checking outProPublica’s ER Wait Watcher.

If you find that your patients are waiting longer than those at a nearby hospital, Donovan and Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing and patient flow, and then help you implement the best solutions to cut wait times. Contact us today at cmd@constancedonovan.com or 651-260-9918.

Sources:
ProPublica: “ER Wait Watcher, Which Emergency Room Will See You Fastest?”

Centers for Disease Control and Prevention: “Wait Time for Treatment in Hospital Emergency Departments: 2009.”

Centers for Disease Control and Prevention: “Health, United States, 2012, With Special Feature on Emergency Care.”

American College of Emergency Physicians: “Emergency Department Wait Times, Crowding and Access Fact Sheet.”