Abstract
With increasing wait times in emergency departments (ED) across America, there is a need to streamline the inpatient admission process in order to decrease wait times and more important, to increase patient and employee satisfaction. One inpatient unit at New York-Presbyterian Weill Cornell Medical Center initiated a program to help expedite the inpatient admission process from the ED. The goal of the ED Bridge program is to ease the patient's transition from the ED to an inpatient unit by visiting the patient in the ED and introducing and setting expectations for the inpatient environment (i.e. telemetry alarms, roommates, hourly comfort rounds). Along with improving the patient experience, this program intends to improve the collaboration between ED nurses and inpatient nurses. With the continued support of our nurse management, hospital administrators and most important, our staff, this concept is aimed to increase patient satisfaction scores and subsequently employee satisfaction.
Introduction
Upon researching ways to improve patient satisfaction, we found two hospitals in the Hallmark hospital systems that have found a way to improve the patient experience. This project (Hallmark Project) 1 was conducted slightly differently than ours but shared the similar concept of easing the ED admission process and improving the patient's hospital experience. The main concept behind the Hallmark Project was a procedure in which inpatient nurses visited the ED to take a report on the admitted patient. This project illustrated that the new process not only increased patient satisfaction scores obtained by patient surveys but also decreased the number of medical errors or omissions related to the handoff process. With this concept in mind, one inpatient unit at NYP Weill Cornell, the Neuroscience Stepdown unit, 2 West, initiated a program to help expedite the inpatient admission process from the ED.
Program description and objective
The ED Bridge Visit program is a process in which an inpatient nurse from 2 West visits the patient in the ED and explains the admission process, along with a brief description of the target unit to which he or she will be admitted. In the process of “bridging” a patient, the inpatient nurse not only introduces herself to the patient but also sets the expectations for the inpatient environment (i.e. telemetry alarms, roommates, hourly comfort rounds). Below is the script for an ED Bridge Visit.
“Hi, my name is ___. I am one of the (nurses/aides/clerks) from __, the unit where you will be going shortly. I wanted to come down and introduce myself and let you know that you have a bed available and will be joining us shortly. Your nurse will be __ He/She will be your primary nurse while you are on____. They will check in on you when they are working and try to be a resource to you while you go through this difficult time. You will be in Room __. A little information about our floor, we are a ______ unit.
You will be on monitor while on our floor at all times and we will conduct neurological and vital checks every two hours unless your medical team decides otherwise. This means there will be some monitor noise in your room, and we will be waking you up somewhat frequently. We apologize for the inconvenience, but please know it is entirely for your safety.
Additionally, we will be conducting Hourly Comfort Rounds. This means either a nurse or a nursing aide will check in on you every hour to make sure you are comfortable, to address any pain you may have and to attend to your personal needs. To save you time once you get upstairs, I brought down some information about our floor and a packet for you to fill out to the best of your ability regarding your medical history. When you get to the floor, please give this completed packet to your nurse. Hopefully we will have you upstairs and in your bed shortly!
See you once escort arrives to bring you to your new room.”
Along with this script, which provides patients with a brief description of the unit, there are prompts for the staff to use during the visit, such as a unit-specific welcome pamphlet. Addressing these points, such as monitor noise, helps set expectations for the patients and their families once they are admitted to the inpatient unit. While performing the ED Bridge Visit, the inpatient staff delivers the admission paperwork for the patient or family member to complete while waiting in the ED. For incapacitated patients who are unable to fill out paperwork on their own, the practice provides an opportunity for family members to complete the necessary paperwork before the transition from the ED, and the paperwork is already completed at the time of arrival on the inpatient unit. In order to enhance collaboration between the ED and inpatient units, the ED nurses have been educated on the purpose of the project. Training has commenced for the inpatient staff on the logistics of an ED Bridge Visit and discussion of key points regarding the inpatient unit in order to deliver a consistent message.
The ED Bridge Visit program consists of different parts that collectively focus on one ultimate goal: to expedite the admission process from the ED to the inpatient unit. Subsequent goals such as improving patient flow, improving employee satisfaction and improving patient satisfaction with the hospital experience are also expected to improve with this program. Along with improving the patient experience, this program intends to improve the collaboration between the ED nurses and the inpatient nurses, a relationship that historically has been strained. The ED Bridge Visit program aims to ease the transition from the stressful ED environment, thus improving patient care.
Assessment/data
In order to measure the effectiveness of expediting the admission process from the ED to the inpatient unit, employee and patient satisfaction have been measured with the use of surveys, both formal and informal. The ED Bridge Visit program has been fully functioning since spring 2013, and data collection is currently in progress. We have measured how satisfied patients and families are with an informal post-visit survey. Data are collected through the use of log sheets that include a patient's medical record number, whether the chart was reviewed, bridge visit time and patient arrival time. We have measured how satisfied the staff is with these visits by performing an informal survey of the stepdown staff. Specifically, patients discharged from NYP receive Press Ganey patient surveys in an effort to measure these results by asking patients whether the staff worked together to care for them and whether the nurses kept them informed.
The 2 West patient satisfaction scores show an upward trend from 67.2 in January 2013, during the beginning stages of implementation of the ED Bridge Initiative, to 90.6 in July 2013 once the initiative was established as best practice. Patient satisfaction topics are also addressed in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, where patients rate their “communication with nurses” and whether the “nurses treat with courtesy and respect” on our unit. These scores at NYP have shown an increase in patient satisfaction for the inpatient unit 2 West with the implementation of the ED Bridge Visit program. 2 West's scores for “communication with nurses” increased from 70.8 during the first quarter of 2013 to 79.6 in the fourth quarter of 2013. The scores from “nurses treat with courtesy and respect” increased from 86.1 during first quarter of 2013 to 93.1 in the fourth quarter of 2013. These markers are reflective of 2 West's efforts in improving the patient's NYP hospital experience. Aside from surveys sent to patients by the hospital, data collection is also comprised of informal surveys of patients and their families collected immediately upon arrival on 2 West. This specific survey collected is a direct measurement of patient satisfaction. Of the 14 surveys collected, 100 percent of the patients and families recalled their ED Bridge Visit, and 100 percent of the sample were either satisfied or extremely satisfied with their ED Bridge Visit. One patient's family member stated, “It was great knowing that my loved one had a room on the admitting unit. I was able to meet the staff and fill out paperwork for the nurse. After the visit, I felt comfortable leaving and getting rest.”
Data are also being collected from the nursing staff in order to measure employee satisfaction. There has been positive feedback on the ED Bridge Visit program from inpatient nurses and staff. The informal staff satisfaction survey included a sample of seven staff members who were asked questions regarding the ED Bridge Visit's feasibility, perception of satisfaction from patients and families, and most important, how this can assist our staff in the admission process. One nurse stated, “My patient was seen by my colleague during an ED Bridge Visit, and we were able to place the incoming patient in a room that had a more appropriate roommate.” Another nurse stated, “I expedited my admission process by having my colleague first introduce the main admission points during a bridge visit and also by having the patient start on his admission paperwork.” The results of the survey also showed that the majority of staff found that time constraints were limiting their ability to perform these visits. However, a majority of staff members reported that ED Bridge Visits help staff expedite the ED admission process. We also found that a majority our staff members feel our ED admissions and families are either satisfied or extremely satisfied with the ED Bridge Visit. Staff reported hearing fewer grievances from patients because factors such as patient room assignments, visiting hours and hourly comfort rounds were addressed prior to entering the inpatient setting.
Lessons
As with any new project, the ED Bridge Visit program has its limitations and barriers to success. When surveying the inpatient nursing staff through questionnaires, one barrier identified was that nurses felt there was insufficient time to visit patients in the ED during the day shift. During the day shift, nurses found themselves occupied with patient care and coordinating treatments with the interdisciplinary teams, and thus, they could not make time to leave the inpatient unit. After discussions with 2 West staff, there has been a realization that this program will take time to become part of the unit's culture. As a result, the night shift staff will have to take more responsibility for initiating these visits, and this practice will primarily take place on the night shift.
Fortunately, the ED Bridge Visit program has been adapted by other inpatient units, especially the medical/surgical general floors. Inpatient Medicine staff reported that they lacked adequate coverage during their shifts to perform ED Bridge Visits. Because the medical/surgical floors have a higher nurse-to-patient ratio, they decided to remedy this issue by sending a nonclinical staff member to perform the visits. One of NYP's inpatient medicine units was sending its unit clerks to perform ED Bridge Visits, which enabled inpatient nurses to stay with their patients.
Perhaps one of the most interesting lessons was about our own staff's expectations. ED staff expected the inpatient staff performing the ED Bridge Visit to then transport the patient from the ED to the inpatient unit, whereas the ED Bridge Visit Program aimed only to welcome the patients in an effort to ease the transition that would ultimately be conducted by the ED staff. We concluded that best practice would be a short welcome and would not include patient transfer. Managers in both the ED and inpatient units have been made aware to this practice.
Conclusion
The premise of the ED Bridge Visit program utilizes Soremekun, Takayesu & Bohan's “Patient Satisfaction Model,” 2 where satisfaction equals perception minus expectation. 2 According to this model, “patients are satisfied when their perceived level of service exceeds their expectations; the larger the difference between their perception and expectation, the higher their level of satisfaction.” This model has been used in other customer service industries and has been shown to improve patient satisfaction when applied to a hospital setting. Patients and families arrive to an ED with preconceived expectations of the health care team.
Health care professionals must be prepared to explore patients' perceptions about receiving care in an inpatient setting, especially during the beginning stages of a patient's hospital experience. With the ED Bridge Visit in place, we have demonstrated an ability to impact patient and provider satisfaction through a nursing-led transition program. The ED Bridge Visit program is now considered best practice for our patients, and 2 West will be working toward making this program part of our culture at NYP. With the continued support of our nurse management, hospital administrators, and most important, our staff, this concept will continue to flourish and improve our patients' hospital experience.