Touch Screens Speed ED Admissions
Check-in kiosks bring Mercy Hospital ED patients quicker care
Monday July 28, 2008
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With ED kiosks, patients enter identifying information and their chief complaint, which is sent immediately to ED nurses. Those who need speed aren't stuck unseen at the end of the line; they're quickly identified, escorted or boarded on a gurney, and whisked to their destinations.
"It can facilitate care in an emergency or when you have a large influx of patients," says Bridgid Hernandez, RN, BSN, ED nurse manager. "At certain times, we get patients by the busload because they come by public transportation. This helps us capture time-sensitive patients who need immediate treatment."
The concept is simple. New arrivals are directed by volunteers or the security staff to a computer monitor touch screen, which uses both English and Spanish. They enter the patient's name and date of birth (used as patient identifiers), then choose from a list of common chief complaints including cough, fever, abdominal pain, chest pain, headache, weak/dizzy, and injury.
"We thought about adding additional questions, but we have a lot of older patients and it was too cumbersome for them," says Hernandez.
When the hospital opened its new ED last November, it added a second kiosk for arriving rescue and ambulance crews to sign in their patients.
The information is immediately transmitted to nurses' computer screens, allowing them to prioritize patients without seeing them. "We can tell immediately that we have patients who are Level I, such as chest pains, and get an EKG immediately to see if they need a bed," she says. "We know which patients are time-sensitive, such as how fast we'll have to get blood cultures and antibiotics for a patient with pneumonia."
In compliance with privacy regulations, the system was created as an alternative to sign-in logs. ED nurses feared individual sheets would create excess paperwork, "and if the paper is lost, the patient is lost," says Hernadez. With nurses' input, a tech-savvy ED physician wrote the check-in software to complement his "bedboard" display that tracks ED patients. The nurses recommended automatic color-coding which shows which patients are awaiting triage, registration, or services, and alerts, such as a flashing "C" for chest pains, and a revolving "P" for pneumonia.
Time stamps showing when patients sign in help staff follow the hospital's best practice timing protocols for specific conditions. It's also important for ambulance crews that must move their patients and retrieve a stretcher before retuning to duty.
"It gives them some flexibility. A triage nurse can come to the back, or if five patients arrive, someone from the back can come up to triage," says Hernandez. Nursing supervisors monitor the display to determine ED staffing needs and whether they'll need to bring in additional staff or open the admissions unit to absorb patients waiting for beds on other units.
Mercy has 32 ED beds and three fast-track beds. The department averages 85 to 90 patients daily, and 32, 000 visits annually.
Big EDs get touchy
Software for a commercial product used at other hospitals was developed by ED staff nurse Jamie Ensminger, RN, at Parkland Memorial Hospital, Dallas, which sees more than 145,000 patients per year, many via public transportation. "We'd have 15 or 20 patients standing in line for 30 to 60 minutes before they got to the first available care provider," says Jennifer Sharpe, RN, director of emergency services. "If someone in serious condition was at the back of the line, we wouldn't know."
Parkland's 74-bed Level I Trauma Center sees 300 patients daily, and as the county's "safety net" hospital, can't divert them when overwhelmed. "There's not a condition we don't see at least once a day," says Jennifer Hay, RN, unit manager. "Cardiac, psychiatric, burn, trauma, neuro, orthopedic, ophthalmology, ENT, [there was] always a line of patients looking at you and you didn't know why they were there. Usually, the patients demanding, yelling, and screaming were less serious, non-emergent, while the quiet ones who stood waiting their turn in no apparent distress had more serious conditions."
Parkland's software is similar to Miami's, with additions. Patients can touch an on-screen body outline to identify their complaint; they're asked if they have specific high-risk conditions, such as diabetes; and can indicate if they need to see a nurse immediately. It also notes other Parkland parameters, such as patients over 50, and red bubbles flagging higher risks and diagnoses. "If you see two red bubbles, you know that patient comes next," says Sharpe.
From chaos to calm
Getting patients out of line and off their feet faster allows them to rest, rather than exacerbate their status. And it eases frustrations.
"There's been a huge decrease in ED violence," says Sharpe. "There used to be at least one incident daily; now it's probably once a week or less."
Low literacy, language barriers, poor vision, age, and legal status don't deter users, she says.
"They feel more comfortable with [the kiosk] there than without it," says Hay. "They have stress and anxiety about coming to the ED in the first place, then worry, 'Is anybody ever going to take care of me?' It's a comfort measure. They know they're not waiting for someone else to sign them in to a computer."
Wendy Bonifazi, RN, CLS, APR, is a Nursing Spectrum senior staff writer.
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