Outpatient Waiting Time and RN Job Satisfaction in the Urgent Care Center

Purpose:
This quality improvement project focused on reducing cycle time for patients with acute ankle and foot injuries at an urban safety net teaching hospital urgent care center (UCC) by evaluation of an extremity earlier in the visit. Decreased cycle time may improve patient and RN satisfaction.

Significance:
Radiology is located separately from UCC requiring 60-90 minutes from X-Ray order to availability of results, extending the total time a patient spends in clinic (cycle or dwell time). National Database of Nursing Quality Indicators (NDNQI) RN survey scores in October 2010 were concerning.

Strategy and Implementation:
The Ottawa Ankle Rules (OAR) identify fractures in the ankle and mid-foot with a sensitivity more than 99% and specificity of 30%. Earlier evaluation and ordering of x-ray potentially reduces the waiting time in UCC. The RN staff was educated to incorporate the OAR into the Medical Screening Exam (MSE) and multi-media training materials supported the education process. Competency was validated by a checklist following individual teaching sessions conducted by the lead Nurse Practitioner. Pre-implementation data collection began January 2011 with post-implementation data available April 2011. Four RNs were initially trained, expanding to eight RNs deemed competent by May 2011. A provider, regardless of initial MSE or x-ray results, determines diagnosis and disposition of patient.

Evaluation:
Patient cycle time was reduced from 244 to 177 minutes. The substantial decrease was a prompt to continue project implementation and data collection. Implementation of this tool in other outpatient units and the emergency department is being considered.

Implications for Practice:
Expedited patient access to services, improved RN satisfaction, empowerment and competency were motivators for project expansion. Improvement in NDNQI RN scores is anticipated. Ottawa Rules for upper extremities should be evaluated for RN use in the UCC patient population.