Some EDs have worked to make sure the nurse and physician are with each other to do the first bedside consult together, with the goal of cutting the number of times the patient has to tell his or her story. Sayah says CHA didn't set that particular goal because of the tradeoff in workflow.
"If we're going to force them to walk in together, that's going to be a delay, because then they have to work around each other's workflow," Sayah says. "Yes, the patient has to repeat themselves sometimes. But it is only two times where it used to be as many as five times before." And the nursing notes are instantly on the Epic-based electronic medical record, he says. "So when I sign on a patient, I quickly look at the nurse's note and I walk into the patient's room and instead of having them start all over again, I would say, 'Well, let me verify what we know so far.' "
One of the most common bottlenecks and opportunities for miscommunication in the ED happens during handoffs between providers. CHA closed that gap by keeping the providers—either the physician assistants or the physicians—tied to the patients from the time they come in until they are discharged, says Melisa Lai Becker, MD, site chief of emergency medicine at CHA's Whidden Hospital campus.
"Once the physician starts seeing the patient, that's your patient," Becker says. "So there's no handoff there. If it's the physician assistant who gets to see the patient first, then they, too, stay with the patient, with very few exceptions. Even with the higher-acuity ones, the PA will continue to comanage the patients with an attending physician." The nursing staff is more geographically bound to a particular set of beds, she says, but in cases where patients are moved from one bed to another for acuity reasons, or through a shift change, nurses "make certain they give a direct handoff to whoever is on the receiving end," Becker says. But most of the time the nurse who met the patient is the one who is there for discharge, she says.