HLM Live: The Purpose-Built Emergency Department Team

Leaders at Sharp HealthCare have developed a pod-and-huddle system built for speed, quality, and communication.

This article appears in the November 2015 issue of HealthLeaders magazine.

If you were to design an emergency department team that could be versatile, facilitate effective teamwork, and dismantle the barriers of traditional ED clogs, what would that look like?

Many modern EDs are designed in a linear flow, attaching nurses or physicians to particular patients and specific tasks. The problem is that linear workflows are vulnerable to uneven staff flow, waiting patients, and a backflow out of the ED to discharge. An ED team built for the purpose of flexibility and even workflow might look something like a pod, or so the leaders at Sharp Memorial have believed for most of the past decade.

The pod, simply, is a unit within a unit. In a Sharp ED, the pod consists of a single physician, a lead nurse also known as the pod leader, one clerk, one bedside tech, and three or four registered nurses. Each pod is accountable for eight to 10 beds per 12-hour shift. In theory, the pod structure is meant to enhance the ability of the ED team to work together more effectively.

"So that really changed the dynamic of the team," says Christopher Walker, MS, RN, NP, CNS, director of emergency services at Sharp Memorial Hospital in San Diego. "It introduces the concept that they're all responsible for all the patients within that pod, not just the three that you're assigned to. So one nurse doesn't put up their blinders and just take care of the patient in front of them. They have some peripheral vision to see what's going on with the patients to their side. That's the only way we'll ensure the highest level of safety and quality for our patients."

In a typical case, the patient is greeted by the triage nurse and assigned an emergency severity index level from 1 (resuscitation) to 5 (nonurgent), which will indicate whether the patient goes back to the ED pod beds or goes to the Sharp ED's quick care unit. Once the patient is in a bed, a pod nurse and usually the physician do the first bedside consult. The ED nursing flow is set up as a primary nurse model (defined as a therapeutic relationship between a single registered nurse and an individual patient), but with some specific alterations that give the nurses flexibility to move from patient to patient as the need arises. Any of the nurses will perform tests and basic procedures and provide education.

"One nurse can get caught up if there's one procedure that takes some time," says Charlene Anderson Dean, RN, clinical nurse for emergency services at Sharp Memorial Hospital. One example is a patient requiring a splint and crutches. Properly placing the splint can take 15 minutes or more, and showing the patient how to use crutches can take another 15 minutes.

"To a layperson, that doesn't sound like a long time," Dean says, "but if you're taking care of three patients and you've got another patient who's in pain that the doctor has ordered medication for, and you're stuck trying to place a splint, then you are taking away from that other patient."

In the pod model, "the expectation is that everyone is in charge of everyone. The other members actively search out other orders that need to be completed," Dean says.

A huge benefit of that model is in staff satisfaction, Walker says. "There's nothing worse than someone having a nice quiet day, thinking over what their patient population is, and the person adjacent to them is drowning."

From a physician's perspective, the pod makes communication more about the patient than trying to remember which nurse was supposed to perform which order.

"It brings a more cohesive team," says Tim Watt, MD, medical director for emergency care at Sharp Memorial Hospital. "For the big chunk of your shift, you're working with the same nurses. There's better communication because that team tends to be together for most of the day. And so people know each other's work styles. I think there's more continuity among the patients. There's fewer hand-offs. I think that's the root of the success."

Overall patient flow is overseen by the pod leader, who monitors the board to see if there are any gaps in care or orders that have not been filled quickly enough. A key component of team communication are the hourly huddles, where the pod team comes together to update status of patients and address any changes that would keep patients in the ED who don't need to be.

While the concept of the huddle is elegantly simple, actually having the hourly huddle consistently is a challenge, Dean says.

"It is difficult to do because nurses are always busy," Dean says. "It is like herding kittens: you get one and bring it in, and then you go get the other one and the first one leaves. So then an hour goes by quickly in the ED and you look up and says, 'Oh gosh, it's been two hours since our last huddle.' That's one reason why the huddles sometimes were being dropped."

Part of the solution was to reinforce the accountability of the pod nurse leader to be responsible for the consistency of huddles. Getting the team together to communicate about patient care is a skill like any other, Dean says.

"We revived the huddles by redoing the competency, and to re-evaluate the huddle leaders that we had, because it is a certified role," Dean says. "You do need to have a competency in the role. If you're not able to manage that time, get your team together, and take control of the pod, then we may not update your competency in that role."

Reprint HLR1115-10