• Case Study
  • September 19, 2019

Move Beyond Static Schedules for Efficient Emergency Department Staffing

A pediatric hospital recognizes local needs and relies on shared decision making to meet variability in the unit.

About PROSPECT

The PROSPECT data program helps hospitals develop appropriate staffing standards, reduce costs and maintain viability in the marketplace. Data supports peer benchmarking and the discovery of improved performance practices.

For more information, contact Carla Hronek.

CHA members: Access recorded webinar and presentation slides here.

What works on paper may not always translate to success when it's tested in real time. The leadership team at Ann & Robert H. Lurie Children's Hospital of Chicago (Lurie Children's) attempted to follow emergency department (ED) operational plans outlined by a consulting group but hit snags. The team realized the two static schedules suggested for the year didn't meet the variability in the unit.

The team members went back to the drawing board and used historical data to identify volume changes. They defined indirect and direct care hours, and better defined the actual productivity time for nurses and paramedics. Those changes and other adjustments contributed to better performance.

To help hospitals uncover trends in data, CHA's PROSPECT program captures a vast library of operational metrics. CHA analysts compared four staffing criteria from PROSPECT to identify high-performing pediatric EDs, and Lurie Children's emerged as one of the top hospitals. Here's how the hospital performed in four areas ranked in PROSPECT data.

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David Kruger is the director of the ED and manages productivity of the unit by focusing on length of stay, left without being seen episodes and worked hours per unit of service. The ED has a set level of FTEs available for safely and effectively staffing the unit.

ED Team Structure

Volume: 56,886
Average Daily Census: 154
High Season: 167
Low Season 137

Lurie Children's uses a variety of strategies to respond to routine and high-volume situations. They rely on agency staff for “up-staffing” during high volume times. Managers also adjust physician schedules to align with the number of nurses on duty.

“There's a lot of different variables we're looking at to paint a picture,” says Kruger. “It's a little bit of science and a little bit of art.”

The physical structure of the unit allows for treatment by the appropriate level of providers based on the patient condition. Three pods are usually open for distributing patients to specific need areas.

  • Pod One: Open 24 hours daily every day.
  • Pod Two: Generally opens from 9 a.m. to 1 - 3 a.m. based on season. The pod is open longer to accommodate a surge.
  • Pod Three: Pediatric faculty provides urgent care

Physician coverage is routinely two providers for days and evenings. If volume causes a delay in patient flow, managers add more shifts.

ED Staff Alignment

Incorporation of a variety of skilled staff enhance efficiencies. Paramedics function as ED partners. Their job description supports response to emergency codes, initiation of IVs, application of splints, administration of respiratory medications, initiation of interosseous lines. Certified nursing assistants have a limited role, but can function in Pod Three as a runner, assisting with transportation and patient flow.

Kruger says in the Chicago market, hospital staff prefer 12-hour shifts over 8- or 10-hour shifts available in other cities.

The team added a psychiatric social worker on all shifts to support the rise in behavioral health patients. The hospital also offers services through a psychiatric residency program.

“We do a wonderful job aligning our staffing model with the provider's side,” says Dan Skarzynski, manager operations. “When managers make decisions about adjusting staffing patterns, it's done in tandem with physicians, nursing and in cohesion with faculty.”

Timely Data, Ongoing Monitoring, and Huddles

Leaders receive the important data metrics for the unit daily including volumes, left without being seen, time to door, time to doctor, time to admission and other measures. These are displayed on a visual management board for staff and patients to view. Every morning, staff hold a huddle at the board to discuss the previous day's data and to plan for the current day. Weekly, the ED operations committee reviews the data in detail looking at trends. One trend discovered during the reviews showed that while volume decreased, the number of critical patients admitted from the ED increased.

Shared Decision Making

Awareness of the trends alerted ED managers to a variance from anticipated seasonal fluctuation. High volumes expected in November and December did not happen. However, volumes began to spike in February and March. Normally, staff are scheduled six weeks out, so leaders adjusted schedules to cover the anticipated volume changes. At times, managers rely on a group of staff with ED experience, known as friends of the ED, to help cover the influx. The group is contacted via text and can respond if they are able to take a shift.

“Our philosophy supports a collaborative environment and shared decision making,” says Skarzynski. “Leadership and staff need to be involved and have an understanding of the big picture.”

Lure Children's created the Proactive Premium Pay Program to take a proactive approach to peak and surge census periods and provide adequate inpatient nurse staffing to support increased volume and acuity.

Nurses must work 36 additional hours over their budgeted FTE status in a three-month period and will be paid extra in addition to their base pay. They can work the 36 hours in four, eight, and 12-hour increments. The contract is only for Lurie Children's nurses and a commitment to the program must be done in advance.

The Lurie Children's team uses EPIC tools to get data about patient acuity, volumes and times.

Continue Progress

Some services in the Chicago area have closed, which is expected to cause increased volumes and growth for the hospital. Managers are planning additional space to meet these community needs.

The hospital has a 14-bed psychiatric unit. However, the increasing volumes resulted in longer LOS and beds not available for new patients. The ED manager considers holding new admissions until appropriate placement is possible. The ED functions with three rooms designed for psychiatric patients, but those are typically full.

Care for complex patients presenting with sepsis, cardiac or hematology/oncology conditions is particularly challenging. Managers are working to fully understand the time and resource intensity of these children.

For more information, contact Carla Hronek.