Nerissa Legge (Host): Emergency departments across the country are working to balance rising patient demand with the need to deliver fast, high quality care. Many are challenged with crowding, staffing shortages, and a continued surge in behavioral health needs.

Hello, and welcome to the AHA Bringing Value series from the American Hospital Association. In this podcast series, we learn about AHA hospital and health system member initiatives and the support they've received from AHA business partners. I'm Nerissa Legge, the Executive Director for the AHA's Hospital Capacity Management Consortium, and Director of Member Engagement and Chapter Relations at the American Society for Healthcare Risk Management.

Joining me today is Megan McCormick, Emergency Department Manager from UNC Rex in Raleigh North Carolina. Today's podcast is brought to you by Baxter International. In this episode, Megan will share her and her organization's strategies to help ED teams work more efficiently, reduce burnout, and enhance patient outcomes. Welcome to the podcast, Megan.

Megan McCormick: Thank you for having me.

Host: Thank you for being here. Let me start here. What do you think are the biggest pressures facing emergency departments, and how are those challenges showing up in your day-to-day work?

Megan McCormick: So, the biggest pressures facing emergency departments, of course, in our local community, statewide, but also nationally, is overcrowding and aging population and the new seasonal and viral surges that we see that have been new since post COVID-19 pandemic. We are seeing population growth in certain areas that are outpacing infrastructure. And there has been changes with access to urgent and follow-up care, skilled facilities and communities, which are reducing inpatient capacity. But also, our patients, as they're aging, their comorbidities have continued to become more and more challenging to manage, which is resulting in increased length of stays in the hospital.

We are managing all of the patients under the sun coming into the emergency department as emergency departments across the nation are treating anyone and everyone. And we are all working together, building relationships amongst teams with transformational and transactional leadership to work together to provide capacity, resources, and really open our doors and our beds to keep care rolling in emergency departments.

Host: Excellent. Thank you so much for that, Megan. Following up on that question, how are ED teams adapting to rising patient volumes, especially when staffing and resources remain tight?

Megan McCormick: With our aging population, of course, nursing is not unique to the aging population. And we are seeing a nursing shortage that has been growing over the course of the last 20 years. As we are replacing nursing and new programs are opening up, there are faculty challenges and, of course, onboarding challenges in hospitals across the country. And so, we are working in a continuum of bringing in new staff and training them across all of the service lines.

But in particular, in the emergency department, we are kind of having to drive the while we're building the road. And so, we are adapting new technology and operational models to help work more efficiently.

One of the strategies that we use in my clinical environment is a very strong partnership with our PI and performance improvement teams so that we can look at our data analytics and predictive modeling so that we can better anticipate the needs of our local community and statewide changes with certain patient populations.

We learned a lot throughout the COVID pandemic as our population shifts were changing. There were the peaks and troughs of the COVID-19 virus, and we were continuing to keep our human resources managed and bringing in contract labor and replacing with permanent staff and getting everybody trained to the same standard of care so that we can provide quality care to our community.

We have been very successful in our local environment here in our emergency department at UNC Rex and, of course, across our UNC system and working to secure local partnerships with our colleges and universities to bring in additional students for precepting and to provide pathways clinically to retain more staff so that not only are they trained in their community that they live in, but that they can transition into permanent full-time clinical nursing or allied health jobs within their own community and healthcare system that they're already familiar with. And we've used some of these strategies just to help with retention and growth and promotional opportunities to help cater towards the needs of our community as we enjoy working and living in a community where we can also be customers of our own health care.

Host: Wow. That is incredible, Megan. Thank you so much for sharing all the great work that your organization is doing. As you've worked to reduce wait times and improve patient flow, have any new practices or workflow changes made a difference?

Megan McCormick: Absolutely. As I mentioned, we do a lot of partnership with our PI or performance improvement teams. And I would encourage every single healthcare organization out there, if they don't already have a PI team, to really forge a strong relationship or build one as they are our data analytics partnership to help us with change management practices.

In our ED, we've been very successful with remodeling the care, how we're operating in our ED. As our ED is not in any way unique and we continue to be challenged by growth in our community. North Carolina is a very desirable place in the United States to live. Everybody wants to live here and everybody wants to get their health care here. And so, we had our traditional triage model that we had to really just change and re-modify with a coupled trial-and-error pattern so that we could safely take care of all patients presenting into our emergency department.

We did a three-phased approach with doing a vertical care model and a triple split flow that is processing patients coming into the emergency department seeking care, managing our patients within a triple split flow as we're able to efficiently maximized bed utilization in our department. But we've also partnered with our hospital's throughput community and our bed placement team so that we can effectively get patients to the right location outside of our department to support increased efforts with throughput.

And if you think of throughput in healthcare, it's similar to the assembly line approach. Input is very much depended on the output so that your continuum of care is seamless and it's continuous. And so, we've been very successful with implementing a triple split flow model here in our emergency department to not only increase our patient outcomes, we've increased our patient satisfaction and experience, but we're also increasing our staff satisfaction to have more efficient models of care delivery in our emergency department.

But while we've done this, we've also been able to build relationships with our inpatient partners, including multiple different service lines like the med-surg, heart and vascular, intermediate and, of course, critical care as our models of being efficient has really translated into the efforts that we're now seeing on the backend of healthcare, which has helped to support more streamlined efficiency with our patient throughput. And we've been very successful in this model, and we've adopted this change about three years ago. And again, while we do a lot of trial and error, this has become our permanent operating model in our emergency department, and we've become a model for care throughout our health care system in the North Carolina.

Host: Wow, Megan, that is absolutely amazing. Thank you so much for stressing, you know, the importance of the performance improvement teams. And it's also really nice to hear about the patient and staff satisfaction increasing. So again, thank you for all the work that your organization is doing.

So, following up with behavioral health, with behavioral health visits continuing to rise, what approaches are helping ED staff respond safely and effectively to these patients?

Megan McCormick: Behavioral health and mental health has continued to present into the emergency departments as this is a national healthcare crisis across the country as behavioral health resources are limited in communities. And especially in rural areas, patients sometimes have nowhere else to go. So, the emergency department is open 24 hours a day, seven days a week. And we have continued to see an uptick in our own community.

One of the things that we have done in our emergency department here is we developed a behavioral emergency response team, which is a model of coverage 24 hours a day, where we staff a nurse and a behavioral health tech that are experts in psychiatry and behavioral health management. And they are a consulting team that our emergency department staff can call on whenever they are needed to not only support as partners in practice with patient intake and de-escalationtion if needed, but also we have brought them into our referral process. And so, they have a component of case management and their experience skill set where they're actually working to expedite the placement of behavioral health patients in hospitals where we don't have inpatient behavioral health resources. A lot of hospitals around the country do not have inpatient behavioral health or psychiatric wards and patients can stay in emergency departments with a term we call boarding as they are not able to leave the hospital but not able to be admitted to an inpatient unit as their treatment requires an inpatient psychiatric care.

So, this behavioral emergency response team has really helped to streamline the efficiency of patient throughput with behavioral health complaints, but they're also partnering with our nursing and allied teams to reduce workplace violence incidents and also increase the safety of the milieu in which all patients are receiving care. We have additionally implemented the use of duress alarms in the campus here, and we are actually going to be spanning those resources hospital-wide. And our duress alarms are a unique badge for every employee. In fact, I have one myself that if a patient is perceiving a risk or has identified an actual event is occurring, they can push their duress alarm. And it sends a silent notification to our security partners who can respond kind of quietly on the backend. And it'll also map clinical teammates and nonclinical teammates within the GPS tracking of our organization. So if a clinical teammate was needing to run, hide or fight, that they could be monitored and trapped for safety reasons so that our security forces and our clinical teams with the monitoring app can find where this teammate is going and we can respond efficiently, but also quietly as to not alert the teammate in distress or a patient that's having a crisis. This model has been shown to reduce our workplace violence incidence.

But we've also not stopped there. We've done a lot of evidence-based literature reviews. We are a host site for graduate students, and we have doctoral students that have prepared research with different workplace workplace violence screening tools and behavioral health assessment tools so that we can work and implement evidence to determine the risk for patients before a risk or a situation even arises.

To take it even further, we've worked with our local security teams and our law enforcement teams to stage additional posts or their locations where they're working within the emergency department, so that there is an officer stationed more co-located to where these patients are receiving care, not only as a show of support for our teammates, but also just to reinforce security measures for the entire emergency department, so that we are providing a safe environment of care, but also a safe environment in which to work in.

Host: All right. So looking ahead, what changes or innovations do you believe will make the greatest impact on emergency care over the next few years?

Megan McCormick: I think that AI, or artificial intelligence, is going to make a tremendous impact in how we are providing care, especially in our emergency departments over the next few years. With the emergency department being such a fast-paced clinical environment, we need information and we need it as quickly as possible. But what we're finding is that a lot of the processes in place in emergency departments and hospitals across the country now is there's a lot of required documentation that our clinical and allied health teammates are responsible and also required to document does take time away from bedside care and patient-facing time. And so, we're really excited for the innovations that are coming and have already arrived to help partner the documentation requirements to complement the care that's actually being provided at the bedside.

I mentioned the duress alarm and its ability to track our teammates. That's one less thing that our staff is going to have to do to run and find our teammates that are in duress. We're able to map them with the use of this technology. But any type of tracking or data analytics that our performance improvement teams can receive can really help to dictate and translate the future care that we're doing. As more literature and evidence is available in the healthcare community, it can be integrated into our electronic records to have predictions if you have patients, let's say, with sepsis that are presenting and unable to participate in their assessment, the records can be integrated with the AI in the background to really give those predictive models and suggestions of what the patient may actually need.

Additional things that we're excited about, there are programs that can really pull in the documented care and provide summaries so that our ancillary teams or any type of remote teams can kind of log in and see what's going on with the patient with really great summaries without having to navigate from different screens to have a condensed picture of what's going on with a patient. It really has a big impact for a small amount of work for our teams. But having said that, it comes with the need to train our teammates on how to use and adapt this technology.

Other things that we're really excited that are coming out are safety features that are built into new technologies and new devices. For example, falls are increasing in emergency departments across the country due to aging population due to patient presentations, and there are new devices and technologies that can actually have falls risk reduction software already built into it, like in stretchers or in additional add-on devices that can integrate with call bell systems. And this gives that activation and alert for warning, not only to the patient, but it can be broadcasted with connected systems so that an alert can pop up on a computer screen, in a communication device that a clinical teammate may be using, but also can go to the unit secretary so that they can get in touch with the clinical team.

And so, those predictive modeling can help enhance the safety and clinical outcomes for the patient. And, of course, we don't have the ability to replace the actual human beings doing this work, but any of the technologies coming in the future that can reduce some of the workload that nurses and, of course, hospital providers are having to do will free up time to give them more time available spent talking with patients, providing care, providing customer service and, of course, including family and friends in the care plans so that patients can safely be discharged from the hospital and have education, teaching, and expectations set forth for when they are leaving the hospital to have a success in their continuing recovery.

So, we are really excited to see what the future holds with regard to evolving technologies. And I do believe the best technologies in particular to the emergency department, because that is an area I am passionate about, is bringing in those frontline emergency department staff, whether it be nurses, technicians, or physicians, and partner with these teammates so that we can bring real life experience from our clinical environments so that new technologies and devices can be created to better support the teammates and hospital workers that are doing the work, providing the care as it's more meaningful and it's been vetted out with opinions and feedback.

And so, the sky is the limit with regard to evolving technology and innovations that are really going to make a tremendous impact on emergency care, especially in these next few years.

Host: Incredible. That's very exciting innovations that we have to look forward to. Thank you so much, Megan, for mentioning all of the information about predictive modeling and various safety features and fall prevention and fall reduction, I think that's very critical to having an impact on emergency care.

 A big thank you to our guest, Megan, for joining today's podcast and sharing her insights with our members. I'd also like to thank this episode's sponsor, Baxter International. You can learn more about Baxter at baxter.com. This has been the AHA Bringing Value Series, brought to you by the American Hospital Association. Thank you for listening.