Cutting-edge Discussions

of Management, Policy, and Program Issues

in Emergency Care

M A N A G E R S F O R U M

Jeff Solheim, RN, CEN

Discharge Call-backs

Interdepartmental Relationships

Electronic Medical Record

Triage Staffing

The opinions expressed are those of the respondents and should notbe construed as the official position of the institution, ENA, orthe Journal.

J Emerg Nurs 2007;33:276-82.

0099-1767/$32.00

Copyright n 2007 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2007.01.010

276

DISCHARGE CALL-BACKS

Is anyone performing discharge call-backs on patients as

part of their customer service initiatives? If so, how is

this being done, and what reaction have you received from

patients and staff?

Answer 1:

We have been attempting to do call-backs on 100%

of our discharged patients the day after their discharge

from our emergency department for more than 2 years.

With our volume, that equates to approximately 130 or

more call-back attempts per day.

Day shift starts the calls at 9 AM and attempts to reach

patients who were discharged between 7 AM and 10 PM

the previous day. The night shift focuses their call-backs

between 7:30 and 9:30 each evening, attempting to reach

those discharged after 10 PM the previous day. Each of our

staff attempts to call up to 10 people, and we only reach an

answering machine approximately 30% of the time.

Initially, many staff members were not enthusiastic

about the idea and were afraid that all they would hear

were complaints, but they soon found out that instead,

they most often received great positive feedback. It actually

allows the staff to grow because it re-enforces the aspects

of care they have given that make a difference in the pa-

tient experience. One unexpected positive aspect of this

program is that it gives our admitting/registration depart-

ment an ‘‘early warning’’ about the quality of the registra-

tion data when we attempt to call a disconnected number.

About 5% of our patients do not seem impressed

with the call-back program, but the remainder are very

impressed that we cared enough to follow up with them.

It has been mentioned positively in the satisfaction sur-

vey comments. Conversely, it also allows us to resolve any

JOURNAL OF EMERGENCY NURSING 33:3 June 2007

M A N A G E R S F O R U M / S o l h e i m

potential customer service issues within 24 hours of dis-

charge.—Aaron Wolff, RN, BSN, Director of Emergency

Services, Catholic Healthcare West, Mercy Medical Center

Redding, Redding, Calif

Answer 2:

Our facility has been making discharge call-backs on our

treated and released patients with a goal of calling 100%.

We have found very encouraging results not only in our

customer satisfaction scores but in our ability to provide

ongoing care after discharge and also as a staff satisfac-

tion initiative.

Our facility sees approximately 70,000 patients per year,

which equates to an average of 190 call-back attempts per

day. The call-backs are done the day after the patient is dis-

charged. The ED nursing director makes 10 to 15 of those

calls, as does the ED medical chairman and vice chairman.

ED performance improvement registered nurse (RN) staff

also assist with the call-backs, but the majority of the call-

backs are performed by the nursing staff and physicians who

provide hands-on care.

The nursing leadership team provides relief for nurses

to do their assigned callbacks each day by either arranging

the assignments between the staff to free up time or cov-

ering for a particular nurse’s patients while he or she per-

forms their call-backs. The nurses are provided a script

on which to base their callback conversation. The conver-

sation usually begins with an opening such as, ‘‘Hello, this

is ___________ from __________ hospital. I wanted to

give you a call and see how you are doing.’’ Follow-up

questions may include such things as ensuring that patients

were able to get prescriptions filled, that they were able

to arrange their follow-up appointment as instructed, or

finding out if they had any specific questions or concerns

about their discharge instructions. The script also may in-

clude questions specific to the particular customer service

or quality initiatives being implemented in the depart-

ment. For example, if we have set a goal that patients will

have an encounter with staff every hour while in the de-

partment, the script may include a question that ensures

that the patient perceived that this actually occurred during

their stay.

We have found numerous advantages since imple-

menting our call-back program. It has allowed us to gauge

June 2007 33:3

the success of our customer service initiatives and also

allows staff to hear first-hand how the customer service

initiatives they are undertaking are being perceived by their

patients. We also have found that the call-back program

allows us to provide a continuum of quality care beyond

the patient visit. Staff frequently re-enforce discharge teach-

ing, assist patients with getting their follow-up appointments

and prescriptions, and validate that our quality standard

of care has been meet. Feedback directly received from our

patients is used as a tool to reward and recognize staff who

have delivered an exceptional patient care experience and

coach those to reach the highest standard of care delivery.

Perhaps most encouraging is the effect the call-backs

have had on our customer service scores. In the most recent

patient satisfaction scores, patients who were home at the

time of their call-back ranked us in the top 99th percen-

tile when asked if they would recommend our hospital to

others. Compare this with the patients who were not home

to receive their call-back; on average, they ranked us in the

68th percentile on the same question. This dramatic im-

provement has been noted consistently in each quarter that

we have been performing postdischarge call-backs.—Lisa

A. Iachetti, RN, BSN, Administrative Director of Emergency

Trauma Department Services, Hackensack University Medi-

cal Center, Hackensack, NJ; E-mail: LIachetti@humed.com

Answer 3:

All of the emergency departments that I work with are

doing discharge phone calls. These calls, when using a stan-

dard script, take as little as 2 minutes per patient (or parent),

and in that 2-minute investment, we gain knowledge of

not only our service delivery but our quality of care and

attention to safety initiatives.

Discharge phone calls allow us to check in on our

patients to ensure that they understood their discharge and

follow-up instructions. This improves patient compliance

after discharge and can prevent return visits to the emer-

gency department. We can ask our patients questions re-

lated to quality care, such as, ‘‘Did you understand how

to take your medication?’’ or ‘‘Did you understand how

long you had to take the medication we gave you?’’ Most

medication errors occur after discharge in the outpatient

setting, so these simple questions can ensure that patients

understand how to take their medications correctly. We

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also can ask our patients if we checked their armband when

we gave them medication for their safety. This ensures

that this important safety standard is being done for

every patient.

Discharge calls can be accomplished by dividing up

all treat-and-release patients the day after they were seen

and giving each staff and physician on shift their share

of calls from the previous day. I recommend a script that

does not ask open-ended questions to ensure that all pa-

tients are asked the same questions and the calls do not

take too long. Set a goal in your department for how many

patients you will attempt to call and how many patients

you will contact or actually speak to. I recommend at-

tempting to call 100% of treat-and-release patients with

the understanding that you will not be able to contact them

all, and a contact rate of 50% or greater.

The reaction from patients is a huge wow. The calls

demonstrate to them that we care about them. This is often

the question on patient satisfaction surveys that we do not

know how to respond to; the ‘‘staff cared about me as a

person’’ or ‘‘staff sensitive to needs.’’

Once we as care providers see what a difference dis-

charge phone calls make to the care of our patients, we love

them. They connect us back to the most important person

in our career world, our patient.—Julie Kennedy, RN, BSN,

TNS, ED Specialist, Studer Group; E-mail: julie.kennedy@

studergroup.com

INTERDEPARTMENTAL RELATIONSHIPS

What things are you doing to improve relationships

between the emergency department and other inpatient

departments to expedite admissions?

Answer 1:

In an effort to improve both relationships and communi-

cation between the ED staff and the staff of other units, we

have implemented 2 programs, the first being a Committee

known as the ‘‘I2C’’ (‘‘Initiative To Communicate’’ or

‘‘Eye to See’’). This Committee is made up of a represen-

tative from each department that affects patient care from

the laboratory, diagnostic imaging, respiratory therapy, die-

tary, and housekeeping to medical records and all nurs-

ing units. At this meeting, open discussion is encouraged

278 J

to hash out issues that affect patient f low and care between

the departments. The Committee has an agenda and meets

on a bimonthly basis. The outcomes thus far have been

positive and productive.

Also, representatives from our emergency department

are selected to attend staff meetings of other departments

and units throughout the hospital. In turn, we invite other

units and departments throughout the facility to send rep-

resentatives to our staff meetings. These programs have

allowed us to exchange ideas, problem solve, and simply

build relationships that can foster an improved patient

f low and allow us, as ED staff, as well as staff from other

units, to see problems and challenges from the other’s

point of view.—Dan Warren, RN, Emergency Services Direc-

tor, Lourdes Medical Center, Pasco Wash; E-mail: dwarren@

lourdesonline.org

Answer 2:

Getting everyone to work together toward a common goal

starts at the top. The first thing that must happen is to have

the president and board of directors agree that there is a

goal. Then they must communicate that goal to everyone

in the organization. Without this, it will be very unlikely

that you can get everyone to work together no matter how

motivated they are.

One way my organization was able to get people on

the same page was to tie the directors’ performance pay to

‘‘66% of all admitted patients are out of the emergency

department within 2 hours of decision to admit.’’ This

stipulation affected not only my performance pay but the

performance pay of all the inpatient directors—radiology,

laboratory, volunteer services—everyone. This approach has

focused all the directors on what the hospital believes is

important.—Robert F. Glade, RN, BS, MSN, Director—

Emergency Department, The Hospital of Central Connecti-

cut at New Britain General, New Britain, Conn; E-mail:

RGFlade@thocc.org

Answer 3:

One of the biggest problems we had was the universal prob-

lem of the f loors receiving admitted patients in a timely

manner. Additionally, they tended to ‘‘pick apart’’ the ED

stay. Because this is a one-way f low, it left the ED staff

feeling picked on.

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M A N A G E R S F O R U M / S o l h e i m

We developed a committee of staff members, with our

patient representative taking the lead on this committee.

Our patient representative suggested that we ‘‘kill ’em with

kindness.’’ Thus, little care packages of candy were made

up for the f loors. When the f loor responds to our request

for assistance in the room to receive a new patient, they get

a care package. It is a little bundle of candy with a card that

explains our customer service philosophy. This approach

has really helped decrease the length of time we spend wait-

ing on staff from the f loors to receive the patient and de-

creases the complaints rendered from the f loor on nitpicky

little things. The majority of the time, staff from the

f loors now anticipates our arrival and greets us with a smile.

It is amazing what a little bit of candy can do!!!—Linda

Thompson, RN, BSN, CEN. Assistant Director, Emergency De-

partment. Iredell Memorial Hospital. Statesville, NC; E-mail:

linda.thompson@iredellmemorial.org

Answer 4:

We have implemented a program where we send each

of our new hires to the ICU for a shift while they are on

orientation. This program gives our staff the opportunity

to understand another department’s point of view. In ad-

dition, each of our new hires spends a shift riding with our

local EMS. Relationships are key to quality patient care.

Adding this to our orientation has been very helpful.—

Janie Schumaker, RN, BSN, CEN, Director of Emergency Ser-

vices, Providence Medical Center, Kansas City, Kan; E-mail:

rschumaker@kc.rr.com

ELECTRONIC MEDICAL RECORD

Does anyone have any words of wisdom as we implement

an electronic medical record (EMR)?

Answer 1:

Provide excellent education sessions to the staff. They

must practice, practice, and practice more. They will not

understand it until they actually start doing chart reviews.

Have them do chart reviews on ‘‘real’’ patients and not

‘‘test’’ patients. Have them find certain information in

the EMR that you look for in your chart audits. Once

they know where to go to find the information, it makes it

easier. Also, you need to up staff for support. We provided

June 2007 33:3

24 hours a day, 7 days a week coverage for 2 solid weeks.

Once we went live with computerized documentation,

we realized how much people did not know about the

EMR, so we educated the staff more in depth at that time.

Because we are a smaller facility, we were able to provide

one-on-one support or at least two-to-one support. Our

full-time RNs are required to do 5 chart reviews per month,

and the part-timers are required to do 2 chart reviews per

month. The last thing you must have is food. Supplying

food with any change makes it go better.—Crissy Mentzer,

RN, BSN, CLNC, Emergency Department Interim Manager,

Waynesboro Hospital, Waynesboro, Pa; E-mail: cmentzer@

summithealth.org

Answer 2:

We have just implemented a ‘‘go live’’ with an EMR docu-

mentation system. The emergency nurses were the first to

do the entire medical record using our workstations (com-

puters). Using ‘‘hindsight’’ analysis, there are several fac-

tors that will make a successful ‘‘go live.’’

The first factor is that the department must have

enough workstations for everyone to access so there is not

a long line of staff waiting to log in. Our department has

a workstation in every patient room with the exception of

the Acute Area. The Acute Area has 6 rooms where we

supplied access to 6 computers in motion (CIMs), and

the Trauma Room has 2 workstations. There were up to 4

workstations at each nursing station, 2 workstations under

each patient-tracking plasma screen, and 2 workstations

in the ‘‘fish bowl’’ area. The ‘‘fish bowl’’ area is used by

outside physicians who come to the emergency department

to evaluate their patients for admission. This may seem like

overkill, but I kid you not, every single workstation is being

used, and we do not have staff waiting in line!

The second most important issue is training. There

is never enough training time allowed, so we made every

minute count. Every clinical employee had 18 hours of

progressive structured training. Staff were also required to

learn each role in the department, then during 4+ hours

of practice time they were encouraged to practice their

own roles with patient scenarios. The scenarios were taken

from real patient charts so the care was realistic. Staff

also had the opportunity to practice in a ‘‘playground’’ en-

vironment when they had extra time. There was no limit

JOURNAL OF EMERGENCY NURSING 279

M A N A G E R S F O R U M / S o l h e i m

on practice time; however, a minimum of 4 hours was man-

datory. The ED ancillary staff also was trained in two 3- to

4-hour sessions, depending on their role in the department.

A ‘‘go live’’ can not survive without the use of sup-

port personel. These ‘‘superusers’’ trained an extra 8 hours,

practiced, assisted with class instruction, and were avail-

able 24 hours a day, 7 days a week, for questions and

troubleshooting. We had a total of 18 superusers in our

group. One was the Physcian Champion, who learned the

system well. The first night we scheduled 10 superusers

to help with the initial ‘‘go live’’ countdown. Several of

us stayed until well into our 15th hour. The next shift

was just as robust with coverage. This extreme superuser

coverage was done for the first 6 days. Then we started

weening our superusers to help with discharges and simple

nursing/clerk tasks.

The ED Analyst Coordinator, Heidi, was available

those long hours, and I was as well. Our presence made

troubleshooting much easier and ‘‘on the f ly’’ corrections

were made to the system. The situation with the printers

being mapped to the correct areas was our nightmare during

our ‘‘go live.’’ The hardware was tested and ready to go.

What wasn’t ready was the printer mapping; we should

have tested that a lot more then we did. We have decided

that there can never be enough testing by the ED Team

(Heidi and myself). Even if the department team is told

that the hardware (printers included) is ready, be sure to

test the application yourselves to be sure. It took 6 days to

get that problem corrected. So you can imagine the frus-

tration from the staff after 6 days of hunting down the

discharge instructions because they never knew where they

would print out at!

I believe the final ‘‘most important’’ issue is to have

a sense of fun in all the chaos—and there will be chaos. I

purchased orange camoflage battle dress uniforms to match

the bright orange ‘‘superuser’’ t-shirts we were required to

wear as superusers. Even the board members appeared in

the department to see our uniforms. The hospital and our

department made sure there was plenty of food (all staff

in the emergency department likes food!!) and sweets for

everyone.—Celia Wallis, RN, BSN, CEN, Emergency De-

partment Nurse/EPIC Project Analyst/Principal Trainer,

Salem Hospital, Salem, Ore; E-mail: caengk@yahoo.com

280 J

TRIAGE STAFFING

What staffing patterns are you using at triage? Do staff

work an entire shift at triage, or do they rotate for short

periods in that assignment throughout their shift?

Answer 1:

Our staff work the entire shift at triage.—Janie Schumaker,

RN, BSN, CEN, Director of Emergency Services, Providence

Medical Center, Kansas City, Kan; E-mail: rschumaker@

kc.rr.com

Answer 2:

We are moving toward a dedicated triage nurse, and our

staff are requesting no more that 4-hour assignments at

triage.—Julia Florea, RN, CCRN, CEN, Emergency Services

Manager, Providence Newberg Medical Center, Newberg Ore;

E-mail: julia.f lorea@providence.org

Answer 3:

At 69,000 visits last year, we staff triage with 2 RNs and

1 f loat RN (who assists as needed) 18 hours per day. The

triage RNs work the full 8 or 12 hours at triage. We have

spoken about breaking up the triage shifts but believe that

would be to disruptive to the continuum of patient care

because someone would have to sign off their patients to

the triage RN. As we know, handoff is a very disconcerting

time for errors and mistakes. The staff rotates through tri-

age as any other assignment once they have the experience

needed and passed a triage orientation with our ED Edu-

cator.—Robert F. Glade, RN, BS, MSN, Director—Emer-

gency Department, The Hospital of Central Connecticut at

New Britain General, New Britain Conn; E-mail: RGFlade@

thocc.org

Answer 4:

We do not rotate assignments during a single shift; how-

ever, qualified staff are routinely rotated through assign-

ments as triage nurse, charge nurse, and direct patient

care. We believe that it is important for staff to maintain

their skills in all areas. Rotating assignments helps pre-

vent burnout in any single area and helps staff to remain

in touch with the unique challenges inherent in each role.

For example, the charge nurse can better understand the

OURNAL OF EMERGENCY NURSING 33:3 June 2007

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Registration co-occurs during com

prehensive nursing assessment. If not com

pleted during the nursing assessment, registration follow

s the assessment.

Assessm

ent nurse goes to the next patient.

SICK (A patient that you would put into your last bed – cannot wait more than 10

minutes)

NOT SICK

Charting:• Name • DOB • Time • Chief Complaint• Triage Class • ABC box on chart

• Chart goes to the rack at the greeters station in the order that the 2nd Triage nurse will see the patients

• Charge Specialist enters info. On tracking board. (time, name, DOB, Chief Complaint, & Triage Level)

• The 2nd Triage Nurse brings the patients into room 2 or 3 based on the order that the charts are in the rack

• The 2nd Triage Nurse completes the Comprehensive Assessment

• The 2nd Triage Nurse places the chart in the chart rack in the triage work room

• The patient goes to Fast Track or the ED when bed available

• The 2nd Triage Nurse initiates protocols and reassessments as indicated.

• 1st Triage Nurse radios Charge Nurse for a bed.

• 1st Triage Nurse transports patient to room.

• 1st Triage Nurse Hand off to Primary Nurse. (The 2nd

Triage Nurse moves into the 1st Triage nurses

, role until the

1st triage nurse returns.) • Leave Chart with Primary

Nurse • Charge Nurse gets info from

Primary Nurse, enters on tracking board, and radios registration.

Patient transported back via Tech, Charge Specialist, or Patient Liaison & handed off to a clinical staff member

Is the patient sick?

Is the patient a 2 or 3 acuity?

Registration Registration

Standard: The 1st Triage nurse always responds to visually see each incoming patient. No delays are acceptable to finish assessments on current patients.

What does the 1st Triage Nurse do when there are no incoming patients? • Repeat Vitals, Reassessments • Assist with Comprehensive Assessments as available

1st Triage Nurse calls the charge nurse for a bed or delegates calling to the

charge specialist

Is there a bed available?

YES NO

• • • • • • • • •1st Triage Nurse is at the Greeter Station / Room 1 Zone BATTLEFIELD SORTING

PATIENT ARRIVES During peak hours (11:00 – 23:30) when 2 triage nurses are on duty.

Definitions: 1st Triage Nurse = Battlefield Sorter

2nd Triage Nurse = Completes the Comprehensive Triage Assessment

Initial Triage Assessment = Name, DOB, Time, Chief Complaint, Triage Class & ABC box on chart

Comprehensive Triage Assessment = Rest of the front page including meds, vitals, etc.

YES NO

FIGURE 1

Flow chart of Harrison Medical Center triage process utilizing 2 triage nurses.

M A N A G E R S F O R U M / S o l h e i m

June 2007 33:3 JOURNAL OF EMERGENCY NURSING 281

M A N A G E R S F O R U M / S o l h e i m

challenges facing the direct care and triage staff if the

charge nurse has recently worked in those roles.

During peak volume hours, we staff our triage area

with 2 nurses. Our goal is for every arriving ambulatory

patient to be seen by a nurse in less than 5 minutes. We

accomplish this goal by assigning nurse 1 to perform ‘‘bat-

tlefield sorting.’’ If the patient cannot immediately be

placed in a treatment room, nurse 2 performs a more de-

tailed assessment, gathers the medication history, and starts

protocols. Nurse 2 also is responsible for ongoing moni-

toring and assessments of patients in the waiting room

(Figure 1—Triage Flow, 2 Nurses).—Louann Sears Bean,

RN, BSN, Director—Emergency and SANE Services, Har-

rison Medical Center, Bremerton, Wash; E-mail: lbean@

harrisonmedical.org

282 JOURNAL OF EMERGENCY NURSING 33:3 June 2007