Drinking the RME Kool-Aid at ENA’s annual conference

Just got back from the Emergency Nurses Association’s annual conference in Minneapolis. Overall a pretty good conference if you avoided the Keynote addresses. A disappointment was the numerous presentations and posters touting the wonders of the process being pushed by several ED groups and Hospital bean counters called RME. Rapid Medical (Mediocre) Evaluation which also goes by several other names such as Triage Bypass, Provider is Triage, Door to Doc, among others depending on which ED Physician group is pushing it. All are basically the same thing. While pieces of the process can streamline care (immediate bedding, bedside registration) here are the claims that are made by the RME’ers that any thinking Nurse should question.

If we adopt RME we will be able to pay for more Nurses with the all the money we Save. Right!!!!! Well, that’s not my experience. I work in one of these facilities and staffing has stayed the same and the moment there is a lull the manager is trying to send staff home because the census is low. So, reduce your standards to move people through, stack them in chairs to utilize more space, pressure the Doc's to do a substandard exam, and as soon as you discharge them go home your not needed. Now that’s efficiency. Remember, work smarter not harder. I have an idea. How about not counting patients who dont get a Nurse in the Nursing hours of care. Most patients are alotted around 2 hours of care credit for budgeting. What if they never get a Nurse. No, that would be way to honest.

Patient should not have to tell their story more than once. Don’t trouble the patient with having to repeat their story more than once. This is team Triage and we get all the facts on the first try because the Story Never Changes!!!!! More Kool-Aid please. What do you call the Nurse in Team Triage? Scribe

You don’t need to have a Primary Nurse assessment. What the heck for. They don’t do that down at the Wall Mart Clinic, why should the ED. And what a wonderful way of dodging the Nursing ratios in California.

Patients do not need to get undressed. What the heck for. You never find anything when you examine the skin, back, or any other covered part. What a waste of time. Yum, Good Kool-Aid. I cant wait for our next round of survey results. Can you say Bump!!

Nurses are more satisfied. Which ones? The ones who view Nursing as a series of tasks rather than a process and don’t assess their patients or understand a Nurse Patient relationship probably will. You know them, the ones who make up discharge vital signs and always have their chart complete even though you never heard any of those questions asked. Yep, that’s them. There are certainly plenty of them around. Managers will also like it. Nothing makes them tingle like good numbers.

Patients can be quickly categorized with minimal or no triage. Put on your Blinders and only focus on the complaint they tell you. It keeps the problem simple. Patients always articulate an accurate complaint and totally understand their symptoms. Easy Peasy. You have an ear ache – Done, Your back hurts – take these, Done. Our Door to Provider times are awesome. Wow, why didn’t we think of this model 20 years ago.

Patients are more satisfied. Some probably will be. Most don’t recognize crappy care as long as its delivered with a smile and done quick. The Customer is always right.

So there you have it. Our professional organization (ENA) pumping up a process that shortchanges patient assessment and treatment from both Nurses and Physicians and cuts out important parts of the Nurses role to make the numbers look good. Brilliant recruiting strategy. I am so thrilled I think I will join for life right after I finish this Kool-Aid.

Top Ten ways to raise your Emergency Department Satisfaction scores

So you’re a Hospital CEO, Emergency Physician Director, or ED Manager. Your latest patient satisfaction scores are lower than your competitor Hospital across town and your in a panic. The results are in the newspaper. Your job is on the line. Try this Nurse’s tried and true top 10 list of how to raise your scores in a hurry. Get your staff on board, here is how.

10. Prescribe Tylenol and other OTC meds: Patients love it because it will mean that their health coverage might cover the cost (at least publicly funded plans will). What’s a little ink on a prescription pad if it moves you up a notch on the survey.
9. Make the Nurses Apologize: Remember, the customer is always right. No matter how dysfunctional and disruptive their behavior apologize if anything upsets them. Smoking in the bathroom, cussing at the Nurses, no problem. If the Nurses refuse have the supervisor apologize and offer the patient a free drink voucher in the cafateria for not meeting their expectations. You can deal with this obvious case of insubordination later.
8. “MR CEO Take down these walls”: Eliminate secure entrances and relax visiting policies. They are only there because those damm Nurses are control freaks. Let the family in and make ER care a group event. Now isn’t everyone happy. More people to practice your scripts on (see #1). Besides, the odds are in your favor you wont have a security event. At least during your tenure as CEO, Director, or Manager. Here is one facility that was not so lucky.
7. Don’t spend to much energy on those excluded from the survey: Quietly leak out who is excluded from the survey (most institutional and mental health patients, and transfered patients in case you are curious) so staff can direct their energies appropriately. Hey, even a demanding CEO knows that you can only kiss so much butt per shift. The key is kissing the right butts.
6. Valet parking: If cost is an issue, lay off your ER Techs, or if you feel bad about that just change their job description, have them put on a suit and park those cars.
5. Prescribe antibiotics for every cough and ear ache: Again, the customer is always right and we dont treat patients, we treat customers. They didn’t drive all this way to get told a viral illness will not benifit from antibiodics and to take Motrin, drink lots of fluids, avoid second hand smoke, and rest. No, give them an antibiotic. Who cares about the treatment guidelines, this one is not measured. They will get better regardless in a couple of days and no doubt will attribute it to the antibiotic. And give them the good stuff, Cipro, makes them feel special and gives you bonus points come survey time. Also good for many bioterrorism events.
4. Hire Travel Nurses: The best thing about Travel Nurses is there easy to get rid of. Yes they are expensive but so is orientation, training, benefits, continuing education, step raises, and all the other stuff that your staff nurses have come to expect. Travel Nurses are not interested in the politics, problems, and shortcomings of the institution, or patient advocacy. They will come to work and not complain, generally be nice, and do as they are told. If they dont, send them packing.
3. Minimize threatening patient education: Crutch walking, wound care instructions, fever control, all great stuff but don’t let those Nurses get to proactive in educating patients. You can loose survey points if some Nurse talks to much about the dangers of smoking, obesity, shaking your child, or any other threatening subject. If the Nurses don’t comply limit their ability to give instructions by eliminating those handouts or use a electronic record that gives instruction control to the Doctor (like Tsystem). After all, Doctor does know best.
2. Provider is Triage: Replace your Triage Nurse with a Midlevel Provider. Your Midlevel can treat and street in a 1 minute Triage exam most of your common complaints as long as they do not engage in any meaningful conversation and follow items 10, 7, 5, and 3 as above. The Nurse, should you choose to keep one in Triage, can stand behind the Provider and quietly scribe the notes. You can call it "Team Triage" and tell them how importnat they are to the "Team". You’ll need a good generic checklist type H&P intake form (I recommend Tsystem or equivalent). The more complex patients will be assigned to the ER for the MD to see. But guess what, you can reduce your ER’s Door To Provider time to nearly zero on all patients by having your PA scribble down some preliminary orders before handing the patient over. Who cares if they ever get done. This is chart buffing at its finest.
1. Scripting to the Test: Teach your staff to memorize the test questions that patients get on their survey so you can have them script their conversation and prompt the patient to remember specifics when filling out their survey. “I am closing the curtain to protect your privacy Mr Jones” will score high on the question “The Nurse paid attention to my privacy needs? “Thank you for choosing Acme Medical Center for your care provider”. This one will get you a more likely to recommend. Not only does scripting guide the patient in completing their survey, it eliminates unnecessary Nurse conversation.

The sad part of this list is the items cited are becoming common practice at many Healthcare organizations.