Published in the November 2010 issue of Today’s Hospitalist
AT NEBRASKA METHODIST HOSPITAL IN OMAHA, a project to boost emergency department throughput by creating a new nursing position has proved to be an unexpected boon to hospitalists.
Because hospitalists are ultimately responsible for reconciling patients’ outpatient medications before starting inpatient treatment, they’re thrilled that the hospital hired a weekday admissions nurse dedicated exclusively to the emergency department. Creating that post has meant that medication reconciliation is now done much more quickly and completely “often before patients even make it to a bed on the hospitalist service.
In fact, says Nebraska Methodist hospitalist Eric C. Rice, MD, MMM, nearly all the patients admitted to his service on weekdays between 9 a.m. and 9 p.m. ” the time the ED admissions nurse is on duty “come with an accurate, printed list of medications, with dosage and route of administration. That list is ready for hospitalists to review, revise and reconcile while the patient is still in the ED.
“We can literally get everything done in the ER and be done,” Dr. Rice says. “I don’t have to sit down and belabor all the med history, go through the chart, look at all the past notes from the clinic and call all the pharmacies myself.”
He also points out the time that the ED admissions nurse saves floor nurses. “Thirty minutes aren’t being spent by the nurses upstairs trying to make sure all the meds are right,” he says, “so they can start therapies sooner.”
Problems with “push-pull”
The hospital created the admissions nurse post four years ago to address a widespread problem: The center was having trouble moving patients quickly from the ED to the inpatient floors.
The problem, explains Sue Rohlfs, MSN, RN, the service executive for the emergency department, was what she calls the “push-pull.” As important as it was to create procedures enabling the ED to “push” patients out faster, inpatient departments needed the ability to “pull” ED patients to the floors. That’s particularly important because the hospital admits about 29% of its patients though the ED.
When nursing administrators studied the handoff from the ED, Ms. Rohlfs says, they learned that it took nurses on the floor at least one hour to admit a new patient. Because most of that effort fell on the admitting nurse, nurses were unwilling to “pull” patients out of the ED. Instead, floor nurses were trying to shift some admissions work back on ED staff.
Over time, the admissions nurse position evolved so that one of the most valuable “and time-consuming ” chores was tracking down and sorting through patients’ current medications. As a result, the entire patient care division, Ms. Rohlfs says, including the ED and all the inpatient floors, shares the cost of that post.
“When you take a new patient to the floor, the most frequently asked question from the receiving nurse is, ‘Did you get the medication list verified and does the doctor know?’ ” explains Ruth O’Donnell, RN, the ED admission nurse. Except for “a very small percentage of the time,” Ms. O’Donnell says she is able to compile a complete admissions medication list for all patients coming in through the ED.
That list becomes part of the electronic medical record, which is accessible immediately upstairs, and it’s printed out for the hospitalists to reconcile. Starting in a few months, that reconciliation process itself will be done online.
According to Ms. O’Donnell, patients in the ED “surprisingly have their list of medications with them about half the time.” In those cases, it takes her only 10 minutes to compile an accurate list. For other patients, it takes about an hour to go through nursing home transfer sheets or to call pharmacies.
Some of the 18 ambulatory clinics that are part of Nebraska Methodist’s health system now prescribe online through a linked electronic medical record, adds Marie Kozel, RN, clinical informatics lead for the Methodist Health System. When those patients come to the ED and need admission, Ms. O’Donnell can automatically pull up their medications on her computer. Some pharmacies are also linking into a new integrated record system that ultimately will connect most providers in the state.
The electronic medical record technology is “quite helpful,” Ms. O’Donnell says, and can “jog a patient’s memory” about what medications they are taking. But it is not the entire solution.
Knowing what you don’t know
Dr. Rice agrees, saying he has come to believe that the involvement of a skilled nurse is key, even with state-of-the-art information technology.
For instance, he says, the admissions nurse has to know to ask patients why they crossed a medication off the list when Walgreens says they are taking it. Perhaps patients respond that their urologist took them off their drug a couple of days ago. That may be a clue to “why they are in here,” Dr. Rice says. “They got taken off a medicine that they really need.”
“All these tools are great,” he adds, “but at the end of the day, you need someone who can integrate the technological tools and actually talk to patients to find out what happened.”
Another major benefit of having an admissions nurse, says Dr. Rice, is that she proactively reports to the hospitalists and floor nurses when she isn’t able to compile an accurate list. “If there is an exception,” he points out, “she notes that for us so we know what we know and what we don’t know.”
The one downside, Dr. Rice says, is that the admissions nurse works only weekdays, an economic decision. The shift was designed to cover the ED’s busiest time and to overlap with the 7 p.m. ED nursing shift change.
After 9 p.m. and on weekends, Dr. Rice says, “I have to revert to doing this the old way, which takes more time and can lead to some inefficiencies.” During such times, he finds that the hospitalists and nurses often duplicate each other’s efforts.
“I could wait for the floor nurse to do it at 4 in the morning and call me, or I could just go ahead and get it done,” says Dr. Rice. The result is “rework and not as much coordination.”
Deborah Gesensway is a freelance writer based in Toronto who covers U.S. health care.