A Nurse-Led QI Project to Reduce ED to ICU Transition Time

Countless studies conclude that the longer an admitted patient boards in an emergency department (ED) the greater the risk for negative outcomes such as falls and hospital-acquired conditions. ED patients waiting for admission to the intensive care unit (ICU) may be at the greatest risk, as they are categorized as critical.

Transporting critical patients from the ED to the ICU requires coordination of multiple clinicians from both units, which can lead to delays. Leading and managing these coordination efforts is a challenge. However we are optimistic as small tests of change have led us to advancements in the timeliness of ICU admissions and improvements in quality and safety.

-Jonathan Nover, MBA RN, senior director of nursing, Mount Sinai Queens

The Project

The ED and ICU teams at Mount Sinai Queens, a 165-bed hospital with 70,000 annual ED visits in Queens, New York, performed a quality improvement (QI) project by developing a collaborative approach between the ICU and ED charge nurses to reduce the median boarding time below 40 minutes.

In February 2023, we piloted a practice change for escorting patients from the ED to the ICU. Prior to the pilot, an ED nurse and ICU provider would escort the patient. During the pilot, an ICU nurse and ICU provider would present to the ED when the ICU bed was clean and escort the patient. A retrospective review was conducted of all ED to ICU admissions, analyzing electronic medical record time stamps for Bed Ready to Bed Occupied. We compared median boarding times in the pre-pilot period from January 2022 to January 2023 (N = 650) with the pilot period from February 2023 to July 2023 (N = 319).

Reduced boarding times. The pre-pilot average of the monthly median boarding times was 64 minutes. During the pilot period, the average of the monthly median boarding time was 49 minutes, outperforming the 40-minute goal in May (37 min) and July (39 min). ICU and ED patient volumes were similar during the pilot and pre-pilot periods.

This QI project found that an ICU nurse and provider response to the ED to escort ICU patient admissions had a positive impact on reducing ED boarding time for ICU admissions. The newly added ICU charge nurse role was a key factor that enabled the ICU team to perform this additional responsibility. Additionally, this project has improved operational transparency, as we are using data to drive our practice. We are making linkages to the literature: Increased boarding in the ED affects clinical outcomes and improving the timeliness of the admission processes can mitigate negative outcomes.

-Geneline Barayuga, MSN RN, nurse manager, critical care services 

-Francelia Thomas, BSN, RN, nurse manager, emergency department

What the Nurses Have to Say About This QI Project

The ICU Clinical Nurse Perspective

Joren Lederman, BSN, RN, CCRN

I have to be honest—at first I didn’t buy into the project because I couldn’t see how a simple switch of going to the ED and spending my precious time just to transport a patient to the ICU would help when I could just stay upstairs, continue my charge nurse duties, and have the ED staff conveniently bring the patient up to us instead.

But I quickly realized the benefits the new protocol gives, not just in terms of RN to RN handoff, but also for the patients. These patients need an ICU level of care for a reason. The ED is usually a very busy place and the nurses there don’t have the luxury of providing one-to-one critical care when the patient is crashing and needs minute-by-minute titrations of lifesaving medications. Being in the ED allows me to immediately start the level of care the patient requires even before transport begins. Instead of ICU staff scrambling to give what the patient needs once they get to the unit, with the new protocol I have already alerted my ICU colleagues to what to expect and whatever lifesaving equipment is needed will already be in place and ready for use once the patient arrives. This protocol has mitigated the element of surprise for all staff and reduced stress, creating a more collaborative relationship between two highly demanding units, the ED and the ICU.

 As professionals, we have the responsibility to maintain an open mind about alternate methods and procedures to improve patient care. We decided to try this new protocol—a simple change, really—and we saw benefits immediately.

-Joren Lederman, BSN, RN, CCRN, ICU clinical nurse

The ICU Clinical Nurse Perspective

Jeremy Enorme, BSN, RN

The pilot project has greatly improved patient safety by reducing the amount of the time a “critical” patient stays in the ED and has promoted better outcomes for our critical patients by not delaying the care that they most need. Also, with the ICU charge nurse transporting the “critical” patient from ED to the ICU, the ED nurse does not have to leave their patients, therefore improving patient safety and reducing the pressure ED nurses face when transporting their patients to the ICU.

Due to this project and the constant communication between ICU and ED nurses, our relationship with the ED nurses has greatly improved. At the beginning of the work shift, the ICU charge nurse communicates with the ED charge nurse to discuss possible admissions and also communicates with them throughout the shift, using EPIC secure chat to coordinate admissions. This has greatly improved communication and fostered a positive relationship between our ICU nurses and ED nurses. Also, the pilot project has helped to establish teamwork between the ICU and ED in promoting patient safety and better outcomes for our critical patients and in not delaying the care our critical patients need.

-Jeremy Enorme, BSN RN, ICU clinical nurse

The ED Clinical Nurse perspective

Our ED in conjunction with the ICU has developed a new workflow to transfer patients to the ICU. Previously, we would call the ICU to give notice that we were bringing up the patient, assemble the team in the ED, bring the patient to ICU, and give bedside report. This was not an easy task, as we would additionally need to coordinate RN coverage for our other patients in the ED. Our new workflow allows the ICU charge nurse and the ICU provider to receive the patient in the ED. While ICU nurse is en route, the ED RN can ensure that orders that need to be carried out prior to handoff are completed and is also able to continue with care of their other patients. This has improved throughput times, RN-to-RN communication, and situational awareness of both the ED and ICU units.

–Maria Dearmas, BSN, RN, ED clinical nurse