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Whangarei nurse PETER WOODS outlines how using a smartphone cut out the 'middleman' and got ED patients more quickly allocated a ward bed.

 

The government's shorter ED stays target had already prompted Northland District Health Board to "streamline" its bed request process once but still patient waiting times could be excessive.

Our initial "streamlined" process involved a bed request form (capturing appropriate clinical information) being emailed from the emergency department (via an iPad) to our duty manager, who would phone the appropriate ward and agree a patient admission time. The bed request form was later faxed to the admitting ward.

The process usually involved a high number of phone conversations between the emergency department coordinator, duty manager and ward coordinator before agreement was reached to admit a patient. The time to physically move the patient to a resourced inpatient bed was excessive and at times contributed to the number of patients who waited longer than six hours within the ED.

So at our daily meetings to discuss breaches of the six hour ED waiting time one of the issues identified as an area of "high need" to reduce breaches was the bed request process. The pictured diagram

 

 

shows the initial "streamlined" system used to request an inpatient bed.

 

Faxes 'filed' in bin

When the bed request process was developed we actually believed that we were using technology to the best advantage but after our review showed the number of contacts required and the potential delay points it was obvious we had potential for further streamlining.

We also realised that smart phone technology could receive an emailed bed request form and that that phone could be carried in the ward coordinator's uniform pocket. When we explored the faxed bed request form, we found that staff did not always use the document and the ward clerk filed them in a 'filing system' – the bin.

The faxed form had been originally set up so that the ward coordinators could use these details to assess suitability of the bed request. However, the fax machine was stored in a back office and busy out-of-hours' ward nurses did not have the time to search out the document.  Furthermore an actual document was given during the formal handover between ED and the ward, negating the need for another document.

 

Smart phone handy in pocket

Each ward coordinator now has a smart phone device in their pocket. The ED coordinators email a bed request form to the ward coordinator; which is automatically forwarded onto the duty nurse manager for their information. This eliminates a number of telephone calls.

The ward coordinator phones the ED within 15 minutes of receiving the email and confirms a bed; the ED coordinator sends the patient to the ward within 15 minutes. Ward nurses can now remain at ward patients' bedside and the bed request document is actually used to inform the ward staff prior to the patient arriving on the ward. This has enhanced patient safety by reducing the number of people involved in the bed request process but also shifted the attention back to the patient. The following diagram shows the new bed request process.

 

Dedicated 'bed request' email addresses were created and allocated to the ward coordinator phones. The organisation's patient flow SOPS (standard operating procedures) were also revised to reflect the new process but more importantly to simplify and embed the SOPs in everyday practice.Training in the use of smart phones varied depending on need and we found the 'non-technical' nurse coordinators embraced the new process as they could see the benefits to patient care.

 

Future improvements 

Our duty managers were using an iPad to receive emails and a separate phone to make calls. The larger newer smartphones can be used for both aspects and having this data in an electronic format allows an easier audit process.

The bed request forms are analysed in detail and a number of improvements have already been made to the document. A future strategy will be to generate an electronic bed request process and improve our ED efficiency.

 

Evaluation

Our initial data has shown a sustained reduction in the time it takes to move a patient from initial bed request to the inpatient ward. Furthermore the nurse managers have created their own audit form to record occasions when they haven't been able to achieve the 30 minute target time.

One of the earlier challenges was the volume of the smart phones when receiving an email. This was either set low or the sound was nominal. Using high volume and a distinctive tone resolved this issue.

There still remain a number of challenges as the volume of ED bed requests outstrip our available capacity but we know that when a bed is available it will be in use within 30 minutes of a request.

 

*Peter Wood RN, BSc (Hons), PGDip HSc is Northland District Health Board's emergency and medical services manager