Productivity of nursing sick call was the subject of last week’s post. Meeting the basic principles of access to care and the right to a clinical judgment requires keeping up with sick call demand. When nurses and managers allow requests for health care attention to go unattended for more than a day they are ignoring these principles and their failure to act puts patients at risk of harm. Sometimes it is hard to picture the cumulative effect of not keeping up with sick call demand. An example of not keeping up with productivity requirements is depicted humorously in the chocolate factory scene on the I Love Lucy show.
How many patients should a proficient registered nurse be able to see in sick call in an hour? This is an important question to consider because sick call must be appropriately staffed to meet demand. Also because sick call is not performed in other settings nurses do not have experience from other settings to inform their own performance expectations. Ten experienced correctional nurses responded to this question. Collectively they have nearly 300 years of experience providing health care in the correctional setting and equally represent jails and prisons of all sizes, in every part of the country. The consensus was on average, seven patients per nurse per hour. Remember this is an average and not an absolute. Factors that contribute to variation from this average include gender (more time is required to see women), health status (patients with complex health problems vs simple concerns), whether requests are triaged first (when not triaged first, all patients are seen even those with scheduling or administrative issues), and location (privacy and availability of equipment or supplies).
Seven patients per hour equates to 8.5 minutes per patient. Referring to the example from last week one nurse could expect to spend three hours each day seeing an average of 21 patients who have requested health care attention for problems that require a nursing assessment. There is also an average of 13 urgent walk-ins that require another couple hours of nursing time. If sick call is taking longer than this or there is a back log, critical examination of the process should identify prospects for improved productivity. Here are some suggestions from our experienced nurse colleagues.
Build competency: It takes time to develop nursing sick call skill. A newly hired nurse may see an average of three or four patients an hour and so staffing should take this into consideration. It is reasonable to expect nurses to have a fund of knowledge sufficient to conduct a focused head to toe assessment but they are not likely to have developed these practice skills in a high volume, primary care setting. An approach to building these competencies is to establish a teaching/mentoring relationship with an experienced nurse (or nurse practitioner) and see patients together. Another approach is to team a nurse with a provider and run sick call and primary care clinic concurrently. This later suggestion may require more elaboration but the idea is that the nurse has more assistance and collaboration available when addressing patient needs so that the number of encounters necessary to address a problem can be reduced.
Eliminate waiting: Ask for help to eliminate time lost waiting between patients. At one facility the nurses didn’t schedule patients for sick call on the facility’s automated scheduling system assuming that it only applied to provider appointments. As a result inmates were brought to sick call only when there was a gap in the provider’s schedule. The numbers of patients seen in sick call each day increased when the nurses started scheduling sick call appointments because waiting time had been eliminated. Collaborating with custody staff may yield other ideas to reduce waiting time especially since sick call competes with other activities they are responsible for overseeing.
Manage time during the clinical encounter: Multi-tasking is a key to managing time during the clinical encounter. Taking the patient’s history and description of the subjective complaint while collecting objective data (taking vital signs, inspecting the area, palpating etc.) is one example. Another is to have the equipment and supplies needed for sick call with you. Stopping the interaction to go across the hall to get a dressing or over the counter medication are time wasters. It is really a waste of time to see patients in a non-clinical setting (cell side or on a tier) since another appointment will be necessary if privacy is compromised, an unclothed exam is needed or a treatment must be given. In other words, handle each request once; don’t generate more encounters because the assessment is incomplete.
Manage the patient: Nurses complain that inmates put in multiple sick call requests, often involving the same problem. The reality is that the primary means to access health care is via sick call. Some systems have looked at the kinds of things that inmates are requesting and considered whether they could be handled through another avenue. Examples of other avenues that have been developed include making over the counter medications more readily available (in the housing unit or on canteen), automatic refills of prescription medication, appointment request forms for the optometrist, mailing lab and radiology results back to the patient, and the list goes on and on. Limiting patients to one request per sick call visit only generates more requests; it is more efficient to address multiple complaints at one encounter. An effective way to manage “frequent flyers” is to schedule appointments with some regularity so that they don’t have to rely solely on sick call requests.
Manage complexity: Several of the experts emphasized the importance of triage in sorting out patients with complex needs and making these the first to be seen. Seeing complex patients early in the day means that there is more time get referrals or additional clinical work accomplished so that their needs are addressed proactively. Explaining this approach of triaging and seeing the complex patients first can also enlist custody staff assistance as necessary. Another approach is to consider group appointments for common problems. I have seen this used at a work camp during a round of winter colds and flu when a quick assessment, patient education and supportive treatment were perfectly appropriate to use in a group setting as long as patients were given the option of a more private encounter.
Contingency planning: No day is ever the same as the next. The number of sick call requests received each day varies and sometimes there will be events that cause the number of requests to skyrocket (e.g. after a disturbance, norovirus or other outbreak, new provider or nurse). A suggested practice is to check in at the half way point; if the number of patients needing to be seen is going to exceed the time available then a backup plan needs to go into effect immediately to prevent backlog. This may mean reassigning staff or re-deploying staff (and mangers and providers) to ensure that all patients are seen timely. Sick call is not a task that gets marked off a list but is instead a dynamic and complex human process that requires attention and commitment to satisfactory completion every day.
How does the consensus of an average of seven patients an hour sit with your experience? What advice do you have for nurses who want sick call to become more efficient? Please share your opinion and advice by responding in the comments section of this post. There is much more on the subject of Sick Call written by Sue Smith in Chapter 15 of the Essentials for Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.
Be safe this holiday season!
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