Our department's mission is to provide Patient-Centered, Evidence-Based Care in a time sensitive fashion to all who seek help 24 hours a day, seven days a week. Like all emergency departments we have experienced large increase in both the demand for our services and the complexity of the care we provide. We (the nurse and physician executive team) strive to constantly meet these challenges. Below you will find our department's journey to where we are today and the road map to our future!
|Mark Rosenberg DO||Maria Christensen RN, MSN|
|Chair, Department of Emergency Medicine||Director, Emergency and Trauma Services|
In 2005 our department had 76,030 registered patients (see charts below) 9% of which walked out prior to physician evaluation. We were operating with a total of 32 beds and at peak had five attending physicians and 12 nurses. Charting was done with paper and pen and tracking systems were nonexistent. Nurses spent significant time just looking for the chart to find patient orders and physicians spent over an hour per shift to obtain and review labs.
The department was home to a well established Pediatrics EM program located in an expanded and recently renovated space, a state designated trauma center, and a recently established emergency medicine residency with a roster of six.
In 2010 we had over 120,000 patient visits and a walkout rate of less than 3% (see graphs below). In 2011 we saw close to 130,000 patient visits and expect close to 140,000 in 2012. We operate, during peak times, with 65 beds in five geographically diverse areas of the hospital staffed by eight emergency physicians and 20 emergency nurses able to handle volumes of 20 patients an hour. Coupled with our increased capacity (patient flow management) to deliver care are robust clinical operations that bring cutting edge, integrated care, to our sickest patients. Below is an expanded list of key elements and processes that are at the heart of our department.
Patient Flow Management
- Weekly ED executive meeting (nursing and physician leadership).
- Physician-augmented triage.
- Data driven staffing approach.
- Midlevel provider-staffed rapid treatment area overseen by triage physician.
- Effective, comprehensive and well integrated EMR.
- Scribes to relieve charting burden of physicians.
- Incentivized physician pay structure.
- Pay-for-performance nursing incentives.
- Podding of beds to maximize physician efficiency.
- Nurse team leaders assigned to established pods.
- Point of care laboratory testing in Diagnostic Unit.
- Push-to-fill bypassing of triage when beds are available.
- Bedside registration.
- Diagnostic unit in triage - Front-loading of test processing (ekg's and blood draws).
- Overflow unit for psychiatric patients to expedite disposition and placement.
- Greeter/quick registration process to maximize patient identification and clinical order 24/7.
- Departmental Spanish translators.
- Hospital-Wide "Bed Ahead" Program.
- Hospital-Wide Electronic Bed Board and Transport system.
- Condition One - hospitalized response to acute, severe ED overcrowding.
- SrED (Geriatric ED) - a dedicated space and conceptual program for our older patients.
- CODE STEMI - one call, ED physician activation of cath lab team for acute MI patients.
- CODE STROKE - one call, ED physician activation of acute care team for stroke patients.
- STOMP SEPSIS protocol for initiation of early goal-directed therapy in septic shock.
- DR. STRONG – one call, ED physician activation of behavioral crisis team.
- Advanced ordering for CHF patients to front load diuretics. (JC HF certification).
- Weekly QA meeting reviewing referred patient charts.
- Credentialed ED Physician Bedside Ultrasound program.
- Infinity - digital radiology images with improved radiology over-reads and result notifications.
- Continuously updated ED physician reference guide.
- FT ED Quality Nurse position.
- Nighthawk" radiology interpretation during off-hours.
- "Yellow Card" process for staff communication of patient safety/operations issues.
- "Dont Drop the Ball" program to increase communication of immediate patient safety concerns.
- Patient Safety orientation for rotating students (medical, nursing, emt).
- Prehospital transmission of ekg's to expedite STEMI recognition and care.
- EMS and ED initiated Mild Therapeutic Hpothermia for cardiac arrest survivors.
- 24/7 availability of Pediatric Emergency Medicine specialists in dedicated Peds ED.
- Procedural sedation for appropriate procedures available for patients of all ages.
- ED and Geriatric care managers who coordinate outpatient care and follow up.
In late 2011 we moved into the newly constructed 88 bed, 183,000 square foot emergency department. It will be located in the hospital's $120 million, four story, critical care building which is part of SJHS's $250 million capital campaign and expansion. The department will also have access to a 14 bed area within the hospital as a possible Clinical Decision Unit. Our new state of the art space is designed to handle over 150,000 visits a year. Goals for our future include:
- Operational focus on measurable changes in patient cycle time.
- Cultural focus on measurable changes in patient satisfaction.
- Innovative approaches to patient safety.
- Exploration of ED's role in protocol-driven observation medicine for previously admitted patients.
- Integration of proven new technologies to support our mission to provide Evidence Based, Patient Centered, Emergency Care.