CONCEPTS, COMPONENTS, AND CONFIGURATIONS

Patients, Charts, and Orders: Keeping Track

Steve Burns, MD John G. Wiegenstein, MD

Lansing, Michigan

A simple, inexpensive system for keeping track of charts, orders, and pa- tients in a busy emergency department is described. All orders, except the most urgent, are communicated in writing. A secretary relieves the nurses of secretarial duties, and functions as coordinator of laboratory work and communications. A traffic board, using magnetic markers, allows instant vis- ualization of the state of the department. Swift movement of patients from room to room can occur without losing track of the patient or his chart. A system of six discrete chart stations is used, each denoting a separate task to be done. The chart moves in an orderly manner through stations, giving the staff "at a glance" information about what must be done and how well the department is processing patients. A scribe option is employed in over- load conditions, allowing a substantial increase in patient processing. Burns S, Wiegenstein JG: Patients, charts, and orders: keeping track. Ann Emerg Med 9:92-95, February 1980. emergency department, systems approach; emergency department systems, tracking

INTRODUCTION

Communications mix-ups are the bane of a busy emergency service. Pre- sented here is a simple, inexpensive system for keeping track of charts, orders, and patients in a busy emergency department. It has worked well at Ingham Medical Center (IMC) in Lansing, Michigan, where 40,000 patients are seen annually. The following are the "vital statistics" of the emergency department at IMC: 40,000 patient visits/year; 10 rooms; 36 physician-hours/day; 72 nurse- hours/day; 24 orderly-hours/day; 24 secretary-hours/day; 36 receptionist-hours/ day; average of eight admissions/day; and an average time from initial registra- tion to discharge of 1.5 hours.

PRINCIPLES

The system is composed of a secretary, a traffic board, and six chart sta- tions.

The Secretary

The secretary serves as the communications coordinator. He processes or- ders, fills out laboratory slips, calls other departments and consultants, arranges for beds for admitted patients, and relays charts containing nursing orders to the nursing staff.

Use of a secretary accomplishes the following: 1) frees the nursing staff from

From the Department of Emergency Medicine, Ingham Medical Center, Lansing, Michigan. Address for reprints: John G. Wiegenstein, MD, Director, Department of Emergency Medi- cine, Ingham Medical Center, 401 West Greenlawn, Lansing, Michigan 48910.

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sec re ta r i a l work and allows them to devote themselves to nurs ing duties; 2) es tabl ishes an unambiguous , reli- a b l e l i n k b e t w e e n p h y s i c i a n and nurse via wr i t t en orders which are in i t i a l ed and t imed when processed by the secre tary . Only in the most u rgen t cases are verba l orders given; 3) charges the specific function of see- ing t ha t ordered l abora to ry work is per formed in a t ime ly fashion. If i t is not, the secre ta ry notifies the charge nurse.

Traffic Board

A busy emergency service must manage its space effectively. Under h igh volume condit ions, only those who m u s t be in a t r e a t m e n t a r e a should be there. A traffic board is an essent ia l tool in good managemen t . Our traffic board (Figure 1) performs the following functions: 1) i t tel ls us at a glance which a reas are in use and which are not; 2) i t te l ls us who is in the depar tmen t , wha t is wrong wi th them, and wha t is being done; 3) i t g i v e s t h e s t a f f i n f o r m a t i o n needed to ident i fy areas conta in ing l o w - p r i o r i t y p a t i e n t s , and a l l o w s those pa t ien ts to be moved wi thout losing t r ack of t hem or the i r charts.

The ex tens ive in fo rmat ion car- r ied by this traffic board is posted on magne t ic tags, which identify the pa- t i en t and his problem, the procedures ordered, and the a rea involved. The magne t ic tags e l imina te ac tua l wri t- ing on the board , and a re qu ick ly moved.

Chart Stations

Arranged in close proximity to the secretary and the traffic board are six phys i ca l l y d i s t inc t s t a t ions where the char ts are kept. The char t moves in an order ly fashion among t h e s t a t i o n s , w i t h each s t o p p i n g p lace s ign i fy ing a d i f ferent p a t i e n t care t a sk to be done.

The six s ta t ions are: 1) new pa- t i en t to be brought back into the emer- gency depar tment ; 2) physic ian to see pat ient ; 3) orders to process; 4) nurse to see pat ient ; 5) pa t i en t wa i t ing (for l abo ra to ry , r a d i o g r a p h y , t r e a t m e n t results); 6) discharge table.

The Scribe Option

B u i l t i n to th~s s y s t e m is t he capaci ty for a subs tan t i a l increase in p a t i e n t p r o c e s s i n g w h i c h can be ut i l ized when pa t ien ts back up. This is accomplished by us ing the scribe option.I, 2

The essence of this option is t ha t i t allows the physic ian to go direct ly

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Fig . 1. Traffic board at Ingham Medical Center. Porcelain board by Rothcoast Company. Card holders by Caddylak. WC = wheelchair; WR = waiting room.

from pa t i en t to pa t i en t in the most expedi t ious manner . I t frees him to concen t r a t e exc lus ive ly on the pa- t i en t he is seeing.

The scribe is a nurse who, when cal led on, leaves his usual dut ies to accompany the physician. With each pa t ien t , the phys ic ian takes his own h i s t o r y b u t d i c t a t e s t h e p h y s i c a l examina t ion and orders to the scribe. Then, while the scribe carr ies the or- ders to the front, the phys ic ian takes the next history.

In this way, the phys ic ian may go di rec t ly from pa t i en t to pa t ien t , only occas iona l ly r e t u r n i n g to the front desk. And the scribe, wi th each

t r ip to drop off orders, can survey the s t a t e of the d e p a r t m e n t . Thus the scribe becomes the eyes and ears of the physician, cons tant ly surveying t h e d e p a r t m e n t a n d s t e e r i n g the phys ic ian from one t a sk to the next. The phys ic ian may devote his com- p l e t e a t t e n t i o n to t h e p a t i e n t at hand.

A genera l l ayout (Figure 2) and specifics of the procedures used (Fig- ures 3 and 4) are i l lus t ra ted .

MATERIALS

The t r a f f i c boa rd is p o r c e l a i n b a k e d on steel and l a m i n a t e d onto wood. I t is f ramed in a luminum. The

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Fig . 2. With the charts displayed in this fashion, each staff member may see exactly what must be done. Bottlenecks in patient processing are immediately and graphically pinpointed. A pile-up of charts at any one station means trouble in that area of department function.

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A Fig. 4. When a n increase i n patient processing is needed, the scribe option may be used.

4 Fig. 3. Procedure followed from the time a patient ar- rives at the emergency department.

9:2 (February) 1980 Ann Emerg Med 94/59

i n d i v i d u a l m a g n e t i c t a g is p l a s t i c wi th a rubber s t r ip magne t glued to the back. This t ag is a card holder into which is inser ted a slip of paper labeled "lab," "x-ray," "admit ," "room 1," etc. The holder is 1% inches by 2 inches, a size which nes t les snugly on the me ta l clip of most cl ipboards and will not become accidenta l ly dis- lodged. Dur ing slow t imes , a l a rge s u p p l y of c a rd ho lde r s c o n t a i n i n g b l a n k paper is p repared for the sec- r e t a r y to use as pa t i en t name mark - ers. The board and m a g n e t i c card holders are both ava i lab le from Cad- dy lak Systems, 201 Montrose Road, Westbury , New York 11590.

On the west coast, the Rothcoast Company manufac tu res a porce la in boa rd . T h e i r a d d r e s s is R o t h c o a s t C o m p a n y , 731 B r y a n t S t r ee t , San Francisco, Cal i fornia 94107.

The r ed m a r k e r s for t he cl ip- boards are -distributed by the Amer i -

can Hospi ta l Supply Company under t h e n a m e " S T A T - C H E C K - - R e d . " T h e y h a v e a p l a s t i c s l i d e r w h i c h moves from side to side, e i ther expos- ing or cover ing up a b r i l l i a n t red. They come with an adhesive backing which wil l hold t i gh t ly to the clip- board.

COMMENT A d d i t i o n a l cons ide ra t ions m a y

be helpful in ta i lo r ing this system. P a t i e n t n a m e m a r k e r s can be

made out by e i ther the recept ionis t or t h e s e c r e t a r y . W h e n t h e r e a r e m a n y phys ic ians a t ag bear ing the phys ic ian ' s in i t i a l can be placed op- posite the pa t i en t he is seeing. Other tags , such as ECG or IPPB, can be added if useful. I t is impor tan t , how- ever, not to overload the traffic board wi th informat ion of secondary impor- tance.

A red flag on the char t is used in

only two s i tuat ions: first, for a medi- cat ion order, and second, when a pa- t i e n t is d i s cha rged and someth ing a dd i t i ona l m u s t be done before he leaves.

When the scribe option is con- t e m p l a t e d , t h e s u b j e c t m u s t be thoroughly discussed with the nurses so t h e y do no t b e l i e v e t h e y are s tenographers . The scribe's function is to be i n t ima t e ly aware of al l the p a t i e n t s and to ac t ive ly coordinate t h e m o v e m e n t s of t he p h y s i c i a n , sending h im from t a sk to t a sk in re- sponse to t he needs of the r ap id ly changing s i tua t ion in the emergency depar tment .

REFERENCES 1. Lynch TS: An emergency department scribe system. JACEP 3:302-303, 1974.

2. Witt RC, Haedtler DR: Nurse-scribe system saves time in the E.D. J E N 1:23-24, 1975.

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