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Quality Matters: Right on Cue

Welch, Shari J. MD; Cheung, Dickson MD

doi: 10.1097/01.EEM.0000413164.02464.5f
Quality Matters


An ED visit is a series of critical health care encounters and events, each involving placing the patient into a waiting line. Unfortunately, because most cannot occur in parallel, they result in long waits and delays. We will process more than 100 million ED encounters in the United States this year, but we still have not standardized best practices for operations and flow.

Most ED patients will be processed through at least seven discrete encounters (even more if respiratory therapy, EKG, social work, or case management are involved). Each event requires a brief communication (a cue) that the patient is ready for the next event. Yet most emergency departments have flawed or inadequate cueing systems, and these result in delays and inefficient patient care.

EDs are noisy places, too, and ED administration needs to think about the communication system, and move away from overhead paging and radio communication and move toward other quieter and focused ways of communicating information, as we suggested in a previous column. (See FastLinks.)

We recommended developing tiers of communication based on the urgency of the message, and dedicating different mediums for communicating information. But who is responsible for that cue in routine ED communications? What is the best way to build those signals into workflow? For whom is the cue intended? What is the best operational means to provide that cue?

We have found that ED staff communicate with one another through many mechanisms including moving charts, placing flags, writing on a whiteboard, turning on a light, placing an icon on an electronic tracking system, phone calls, buzzers, and radios. Multiple cues may be used for the same event; a patient's arrival may prompt a radio call, for instance. The best cues in the ED can be generated and seen from multiple locations in the ED. The person receiving the cue also must be able to recognize the cue. Using paper charts or a light over a room can be inconvenient to trigger the cue unless you build it into workflow.

Some common events are implicit in an ED visit, and EDs can assign who is likely responsible for the cue, who needs to receive that cue, and some of the methods employed to do this. (See table.)

ED communication will be all electronic one day, but most EDs still generate a chart and move paper around during a patient's ED visit. (As an aside, many with electronic tracking systems say the Lilliputian icons on these boards have less impact on staff than older low-tech methods like chart movement and flagging.) An almost universal problem in emergency departments is the misplaced patient chart. This is problematic because each member of the ED team interacts with the chart in the course of patient care.

One efficient mechanism for cueing is to use the chart itself in a particular location (usually a rack or bin) to communicate the next cue. Carefully articulated chart flow can mirror patient flow, and the chart can be physically pushed to the next team member or provider or who needs to interact with it, a convenience for that person. The nurse simultaneously receives the chart to tell her that she has new orders, and she has the chart in hand to administer those orders. Staff must have discipline about chart placement and not leave charts in patient rooms and in charting areas unattended, and the practice of hoarding charts by physicians or nurses should be strongly discouraged. Charts should have a “home” when they are not cueing a team member or in use by a provider.

A few final points about the humble ED clipboard chart: All charts should have the patient name and room number easily readable from a distance. This greatly helps with ED operations for everyone. Color coding paper and a standardized arrangement of the papers in the chart also facilitate efficient chart utilization. One ED used pink discharge paperwork so that the pink stood out in the chart rack to signal a discharge. A novel but extremely efficient practice involves using translucent acrylic clipboard charts. The triage or intake notes can be placed face down as the first page of the chart. The physician can read those notes through the clear acrylic without thumbing through page after page to find them. He then flips the clipboard over to begin writing on his portion of the chart.

Though perhaps not a sexy or compelling project, outlining the regular cues you need and use in your department will greatly improve chart flow, workflow, patient flow, and efficiency. Take a few hours with key stakeholders to look at your current process. Using a version of this table to articulate your cues, run through each one and ask yourselves, is this the most efficient way to do this? How and where charts move will be influenced by the layout of the department, where the clerk sits, and where the nurses and physicians work. You can likely fine-tune this aspect of work flow in your department in short order.

Well placed signage can help early on with any changes in chart flow. (And don't forget to post information about any changes in all staff restrooms and lounges where the real important news should be posted!) Just ask some of the more creative members of your team to find low-tech ways to improve the ease and efficacy with which you cue one another. Surely an operational thinker among you is up to this task. You will likely find improved work flow and patient flow right on cue!

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Dr. Welch is a fellow with Intermountain Institute for Health Care Delivery Research, an emergency physician with Utah Emergency Physicians, and a member of the board of the Emergency Department Benchmarking Alliance. She has written two books on ED operational improvement; the latest, Quality Matters: Solutions for the Efficient ED, is available from Joint Commission Resources Publishing. Dr. Cheung is an Efficiency Consultant with Carepoint PC in Aurora, CO, a Malcolm Baldrige National Quality Award Examiner, former faculty of the Johns Hopkins Center for Innovation in Quality Patient Care and the Quality and Safety Research Group, and a member of ACEP's Quality and Performance Committee.

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▪ Read Drs. Welch and Cheung's article, “Enterprise to McCoy: The Future of Communications in the ED,” at

▪ Read all of Dr. Welch's past columns in the archive.

▪ Comments about this article? Write to EMN at

© 2012 Lippincott Williams & Wilkins, Inc.