Sharonda Brown, BSN, RN: Reducing the Amount of Patients Leaving Without Being Seen

In the final of a 3-part interview with MD Magazine, Sharonda Brown, BSN, RN, a senior emergency department consultant with American Academic Health System, at Hahnemann University Hospital, spoke about the overall efforts to see patients in a timely manner, ensuring that timeliness and quality go hand-in-hand.

Brown also discussed the focus on capturing patients that normally would have left without being seen, and how culture changes have cut that percentage almost in half—from about 13% down to about 7%. She also talked about how the administration at Hahnemann have worked with the nursing staff off-scene to stress a team approach to training and buy-in, and how the hospital has taken evidence-based methods in order to tailor a “Plan of the Day” for the emergency department based on the available staff and resources.

Watch the previous installment, Part 2 of the interview, here.

MD Magazine: There's been a focus on decreasing the number of patients that leave the ED without being seen—how did that come about?

Sharonda Brown, BSN, RN, a senior emergency department consultant with American Academic Health System:

Most definitely with the case reviews. Speaking about cardiac patients, stroke patients, remember the phrase “time is tissue.” If we don't move, if we don't diagnose you quickly enough, we're in trouble. It's being able to identify who is in our lobby, who is in the waiting room waiting to see a physician.

They have multiple complaints and you have to understand—we’re the experts, the patients are not. They'll give us tons of symptoms that they may be having, but we have to be able to differentiate them in a timely manner in order to meet their needs and have better outcomes. So, it’s speaking to them about those quality outcomes and what to do.

Studies have shown that if we don't reperfuse your arteries within 60 to 90 minutes—we're going for 60, I believe the national standard is 90, but we're going for 60 minutes—if we don't reperfuse your arteries, your chances of leaving out the way that you came in, in a good condition where you’re able to go out and run and jog with your kids, it's slim to none if we don't do that in a timely manner. So, timeliness is quality.

We tackled left without being seen initially, and it was focusing on the front end. Changing that traditional triage process to a quick look. Sorting the patient versus a tedious process, again, of non-value-added steps. Decreasing the questions that we asked when it comes to registering you. Not asking for your address, or to confirm any of your demographics, solely name and social security number, just so you could pop up in the system. Doing those type things, so we can get you in the system faster and, again, shifting those mid-level providers to the front end to capture those patients that were leaving without being seen.

Think about the perception of the patient. I've seen the doctor, I've seen the mid-level provider, I'm being treated. That perception alone keeps our patients here and has decreased our left without being seen percentage from about 12.9% to 6.9%.

Well, it has streamlined things for the staff, but this is a cultural change. Now, we're working with the group of nurses that have been doing things one way for so long and so it's very important that we work with them off-scene. When I say off-scene, I mean not out on a unit. We have to make sure we work on process improvement initiatives outside of here. Training is key, and buy-in is key, and so we have to give them those evidence-based studies and practices. Just tell them what others are doing, and how we need to meet the same standard of evidence-based practices.

We're not the first ones to have done this. We've definitely replicated what we've learned as well. Taking that evidence-based method, and then tailoring that to Hahnemann, tailoring that to your emergency department. What works for your team, what works for your patient population, is key. We have, what we call right now and at this particular institution, a Plan of the Day because things change. Our acuity levels change in the emergency department, our staffing skill level changes, and so does our physician staff, right? So, that kind of change from day to day. What we try to give them—or what we do give them—is the basic principles of the processes, and we allow them to tweak it to what works best for them. It's definitely a team approach, so everyone has to have their input.

Transcript edited for clarity.