Answer

Workflow Distribution in an Emergency Department

Introduction

Emergency department   are used for life threatening cases like stroke or accidents. However, other less critical conditions may be seen. Emergency departments are normally filled to capacity. To enable correct clinical evaluation and treatment, the emergency department is divided into four critical areas; pre-triage, triage, waiting and treatment areas. The pre-triage is the initial step from where the nurse will either refer you to the triage nurse, waiting room or treatment area. A tried nurse will do further assessment and refer the patient for treatment or to the waiting room. The final step is bed allocation where a district nurse will monitor the patient as he/she is undergoing treatment. Aronsky et al. (2008) defines triage as “a fast-paced process that prioritizes the allocation of limited health care resources to patients in greatest need”. This paper aims to create a workflow diagram showing the processes from arrival, treatment to registration in and emergency department. The workflow will be used to identify weaknesses in the processes involved and to recommend changes.

Admission Process

The first step on arrival is to be received by a nurse who performs preliminary assessment where the patient provides the reason for the visit. The nurse also indicates the patient’s name, age and the major complaint. Depending on the assessment, the patient may be taken for treatment or to the waiting room. All patients must pass through the pre-triage nurse unless the patient is arriving by ambulance then he goes straight for treatment. The files are arranged with the most urgent at the top of the list. The triage nurse then takes the chart at the top and finds the patient in the waiting room. A clinical evaluation is then done on the patient. The patient’s vitals are recorded on a printed chart. The patient is assigned an emergency category and any tests that are indicated are ordered. The nurse then enters the data in a computer system whose function is tracking patients.

Depending on the workload of district nurses available in the treatment areas, the triage nurse will decide where the patient will go. Communication among the triage nurses is essential at this point to avoid sending two patients to the same area. The assigned nurse and area are indicated in the chart. Afterward, the patient is either taken to the emergency department treatment area or the waiting area. After the triage nurse hands over the patient to the district nurse and provides all the necessary information about the patient, the chart is finally given to the registration who enters the data into the electronic patient record. The pre-triage and triage nurses use printed papers to fill the patient’s details. The triage nurse later transfers all the information on the chart into a computerized patient tracking system.

The pre-triage nurse is tasked with determining the level of urgency and taking patient information.  At this stage the privacy of the patient is critical and governed by the HIPAA. Most hospital policies provide the emergency department its own floor. A pre-triage nurse does her/his work in an area near the entrance of the emergency department and near the waiting room to allow for easy identification of new patients and movement to the waiting area.  To enable tracking and billing process, the information required includes age, address, and medical history including any current medication. This is important in order to effectively deliver health care.

The triage nurse will also assign level of urgency to a patient after performing an assessment. She/he will fill the results of the examination in the chart that the triage nurse had started with. He/she may suggest that further diagnostic tests to be performed. In order to facilitate adequate patient care, necessary patient information should be made available to all the concerned parties. In accordance with this policy, the triage nurse enters the information gathered so far into an electronic tracking system. According to McGonigle& Mastrian (2012), health information is critical in providing sound clinical decisions.

Policies governing the emergency department provide for priority of treatment to be based on urgency or severity of a condition (McGonigle& Mastrian 2012). That is why a triage nurse can send one patient to the emergency waiting room while the other is directed to the treatment area. At this point, patients who only came for consultation are recommended for discharge. Additionally, some minor conditions can be addressed eliminating the need to assign a bed. Patients arriving in ambulances do not pass through the waiting or triage stage.  Life threatening cases are given the first priority. Patients are advice to inform the triage nurse if their condition changes. This is important since most of the time emergency department is packed to capacity where bed allocation is determined by emergency and it is common for patients to wait for long periods of time in the waiting room.

The district nurse is responsible for providing ongoing care to patients referred by the triage nurse. The patients wait for results from their tests as they are being monitored. In contrast, the clerk is responsible for completing the registration process where the patient’s information as presented by the triage nurse in addition to insurance information and consent forms are fed into the system.

Recommendations

The waiting room can be incorporated with physicians, triage nurses and other practitioners needed to treat minor cases to prevent overcrowding and increase efficiency of health care delivery. In addition, the use of papers during triaging is not only inefficient as more time is taken to duplicate the same information on the record system but also introduces avenues for errors during duplication. Additionally, although the system for tracking district nurse availability is computerized, regularly updates are sometimes not done resulting to triage nurses committing to memory who has been assigned where increasing the inefficiency.  An integrated electronic system can be used to integrate tracking and electronic medical record (EMR) systems to enable faster triaging. EMR enable more time to be allocated to patient care as opposed to documentation (Gruber et al., 2010). Since the pre-triaging nurse is located near the waiting area, there is a risk of confidential information being overheard. Providing a separate area where privacy can be observed will serve to preserve patient privacy.

A workflow chart is important in providing insight to how tasks are performed and the processes involved. It enables spotting duplication in activities and irrelevant tasks. This is helpful in looking for ways to optimize operations as flaws in the processes can be identified.

Conclusion

Emergency departments use both paper and electronic means to enter patient information. However, paper systems lead to inefficiencies and poor delivery of care. Using technology to speed up and increase efficiency is therefore a viable option. According to Fickenscher& Bakerman (2011), such a change is bound to present challenges and staff needs to be eased into the change. Such change is only possible with innovative leaders in health care (Hyrkäs& Harvey 2010).