Nemours Children’s Hospital ED expedites triage process with RN as pivot person
Before the Nemours Children’s Hospital opened in Orlando last October, newly minted Emergency Department (ED) chief Todd Glass, MD, collaborated with Nemours’ nursing director Nicole Johnson on the best and most expeditious way for pediatric patients arriving in the ER to see a doctor.
“We focused on designing processes comprehensively to deliver early assessments and get care to the patient as soon as possible,” said Glass, board-certified in pediatrics and pediatric emergency medicine. Glass joined Nemours from Cincinnati Children's Hospital Medical Center (CCHMC), where he served as the medical director of the ED at CCHMC's second hospital campus, which opened under his leadership in 2008. “Before we opened Nemours, we wanted to take away obstacles that would delay a child being seen by a doctor. We asked parents what they wanted, and they said ‘to see a doctor!’”
By placing a registered pediatric nurse as the ED pivot person – the first point of contact for incoming patients and their families – Glass was able to fast-track the triage process and see patients more quickly. Since opening in October, the Nemours ER average waiting time to see a doctor or nurse practitioner is less than 10 minutes.
“A few years ago in Cincinnati, when we first put a nurse at the greeter desk, it was new, but made perfectly good sense. It only takes a minute or two for a nurse to assess a patient,” said Glass. “The pivot nurse inputs the patient’s name and birth date into the system, and then we move from there, effectively eliminating 30 minutes usually required upfront for full registration, which is done on the back end of the ER visit.”
The ED front-door assessment has already had a life-saving impact.
“Several weeks ago, a pediatric patient with complex medical problems became ill at home,” said Glass. “Her mother pulled up to the ER entrance and asked for help with her child. The nurse picked up the child from the car and was aware right away the child was critically ill. She had gone into cardiac arrest. He took her immediately from the doorway to the resuscitation area, where she was successfully resuscitated. Typically, the first point of contact in an ER who answers questions – a clerical staffer or a security person – wouldn’t have been as aware of the symptoms. On his way to the resuscitation room, he told the staff to activate the code to page the teams. The child’s care was initiated within 1-2 minutes of the mother pulling up to the door. That’s one of the things that saved her life – expediency of care – in addition to receiving very good care.”
Glass has established an ER protocol that a team – the physician, nurse, and paramedics – works together for patients, whether critically ill or cases not as complex, as soon as they get in a room. Nemours’ ED has 18 private rooms where patients’ families are invited to stay during procedures.
To help the medicine go down a little easier, the ED has a Slushee machine for children.
“We don’t want a child to take medicine too fast, so this prompts them to drink slower and there’s less chance of vomiting,” said Glass. “Plus, a Slushee just tastes good.”
The ER triage process and elimination of time-consuming front-end paperwork has improved the average length of stay for patients – 80-100 minutes in the ED.
“Obviously, groups with the shortest lengths of stay are critically ill,” said Glass. “We focus on getting care started to stabilize the patient and get them transferred to the critical care unit. The other group with very short lengths of stay, an average of 45-70 minutes, includes those who have very straightforward cases. It takes longer during peak hours; that’s the nature of an ER. We’ve never had a 6-8 hour wait time. Almost everyone goes home (or is admitted to the hospital) in less than two hours.”