ED management : the monthly update on emergency department management
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By empowering front-line staff to come up with some of their own solutions, the ED at Swedish Medical Center in Issaquah, WA, has implemented a no-wait model that eschews traditional triage in favor of a rapid intake process that puts patients in beds immediately and kick-starts the evaluation process. While the approach has proven challenging to implement and maintain, patient satisfaction is greater than 95%. ⋯ Key to the approach is a team-based system that puts all personnel on the same level with no hierarchical structure. In the model, charge nurses are under constant pressure to make sure a room is always available for the next patient, and nursing staff are empowered through protocols and standard order sets to respond to patient needs before physicians complete their assessments.
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Experts say under-triage is a serious problem in EDs across the country, and the issue has serious implications for patient outcomes. For example, patients who are deemed urgent but stable can deteriorate quickly if they are more ill than the triage nurse initially determined. ⋯ Routine chart reviews can help ED nursing leaders determine whether under-triage is a problem, and which nurses may need added training in triage to improve their skills. Rather than rotating all emergency nurses through the triage role, ED leaders should carefully evaluate which nurses have the high-level skills needed to make accurate triage decisions.
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A hospital-wide improvement effort has enabled Robert Wood Johnson University Hospital in Hamilton, NJ, to reinstitute a guarantee that patients arriving at the ED for care will be evaluated within 15 minutes and receive a medical examination within 30 minutes. Administrators used a team approach to identify bottlenecks and implement solutions, and they divided the ED into four zones, with provider teams responsible for each zone. ⋯ The zoning system in the ED has improved patient throughput and fostered accountability within the care teams responsible for each zone, say administrators. Overall care provider satisfaction has risen from the 75th percentile in 2010 to the 80th percentile in 2011, according to Press Ganey surveys.
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Clinical pharmacists with EM training slash medication errors, help to optimize therapies in the ED.
Pharmacists who specialize in emergency medicine are taking a place at the bedside in a small but growing number of EDs. Studies show the approach can make a big dent in medication errors and can quickly guide physicians toward optimal therapies with respect to trauma patients and other complex cases. Experts say clinical pharmacists provide an extra safeguard that is commonly missed in the fast-paced ED setting. ⋯ Pharmacists serve on trauma teams, review medication orders, assist with medication titration, and act as a communication bridge between the ED and the inpatient pharmacy. Recent studies suggest pharmacists capture significantly more medication errors than other personnel, and that they help to speed patients with ST-elevation myocardial infarctions from the ED to the cardiac catheterization laboratory. Nurse and physician buy-in are critical to the success of a clinical pharmacist program in the ED.
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A record-breaking number of drug shortages is impacting all areas of health care, but ED and EMS operations are under added pressure to work around such shortages quickly to meet critical patient needs. Experts say the most successful organizations have established strong communication channels between hospital pharmacists and providers so that when shortages arise, alternative approaches can be devised and communicated swiftly. By mid-September 2011, 213 drug shortages had been reported to the Drug Information Service at the University of Utah Hospitals and Clinics in Salt Lake City. ⋯ Experts say early recognition of drug shortages is essential so that providers and pharmacists can prioritize resources to optimize patient care. There is broad support for legislation under consideration in Congress that would require drug manufacturers to notify the FDA of anticipated drug shortages. Experts believe such action would enable the FDA to take steps to prevent many shortages from occurring.