Photo submitted to Times Observer Physician Assistant-Certified (PA-C) Jennifer Gray has been one of the key advanced practice providers through the Warren General Hospital Emergency Department renovations.

Warren General Hospital has nearly completed the first phase of a renovation of its Emergency Department.

Thanks to a $3.7 million Redevelopment Assistance Capital Program (RACP) grant from the state, it will begin working on Phase II next year.

“We’re very grateful to (Rep.) Kathy Rapp and (Sen.) Scott Hutchinson for their support,” Warren General CEO Rick Allen said. “The emergency department is a window to our community. It’s a critical service to us. That’s very, very important.”

“The better ER we have, the community responds to that, the quicker we can do door-to-provider… door-to-door,” Allen said.

“Phase II is an expansion of rooms, and expansion of capabilities of the rooms to include behavioral health,” Chief Nursing Officer Joe Akif said. “It is to provide new ergonomic work-space for the providers.”

And, the work will bring negative pressure to all of the rooms in the ER, making it better prepared in the event of a pandemic or a return of COVID-19.

When complete “our ER should take care of us for the next couple decades,” Akif said.

There will be 10 treatment rooms in the emergency department — up from nine before the renovation. Ten is a good number for the hospital.

“An average ER should see 1,750 to 1,800 patients per room year,” Akif said.

With a total of 16,500 and 19,000 patients presenting at the emergency room every year, splitting those into 10 rooms hits the target.

“For Warren County, if you look at our declining population, we’re well-situated when Phase I and II are done,” Akif said. “We should be able to handle this population efficiently.”

Of those 10 rooms, four will be “psych-safe… patients are then in a room where they can’t harm themselves,” Akif said.

There was one such room in the ER prior to renovations. When there was a behavioral health patient in one of the non-psych-safe rooms in the ER, someone on staff had to remain in the room with them at all times.

Phase I of the project got the ball rolling.

Jennifer Gray, PA-C (physician assistant-certified), has been one of the advanced practice providers at the center of the work since the beginning. She has seen the changes first-hand.

“We’ve had a lot of positive changes,” Gray said. “We’ve brought on two new physician assistants and a nurse practitioner. Out in triage we have three new triage bays. It gives us more space for patient care.”

“We took a one-bay triage area and made that into a three-bay triage area,” Akif said.

The change to the space allowed for changes in the way patients are received.

“Not only does it increase our capacity to take care of patients, it also improves our efficiency,” Dr. Mike Faulk, Medical Director of Integrated Acute Care and Emergency Department Director, said.

“Door-to-doc” is an industry term. For now, Warren General is working on “door-to-provider” — not necessarily a physician. “We were averaging about 59 minutes,” Akif said. “We’ve gotten it down to about 11 minutes.”

“That really is fast,” Allen said. “That’s a significant number.”

He said if the department can consistently maintain that average, “that’s outstanding.”

“The old model would be, patients would come in and be seen initially by a triage nurse,” Faulk said. “Now, at least six days a week, our patients are initially seen by a provider — an advanced practice provider.”

“That triage process now will be done in collaboration with a nurse and maybe an emergency department technician,” Faulk said. “That workup and treatment will get started right as soon as they walk in the door. The advantage of having the system where a provider is seeing the patient right up-front, there may be times when the patients are still staying in the waiting area, but things are happening.”

“We’ve developed an individual who helps with blood draws and EKGs to assist the nurses and the mid-levels to do their job, top-of-license,” Akif said. “It’s more support for them. Otherwise, a mid-level writes an order for something, but the patient sits there until someone is available to do it.”

Bringing down the door-to-provider time brings down the door-to-door time.

Akif said the treatment time for a young person who gets injured playing sports could vary widely.

Going initially to the family’s primary care physician “can take anywhere from four hours to four days,” depending on the testing and treatments needed, Akif said.

A visit to the emergency room would be quicker.

“Our old practice… you come into triage, the nurse sees you,” he said. The injury is not life-threatening.

“You’re lower acute,” he said. “All the other acuities would go ahead of you. That would take you anywhere from one to four hours.”

“Now, with this type of a process, you get the care started in triage by a mid-level provider, that will bring your length of stay down,” he said. “It will take 60 to 90 minutes from presentation to discharge.”

“If someone has a sprained ankle… they want it wrapped. They want to be home,” he said. “If someone comes in and they have a cold, or they just need a medication refill… you might have to wait sometimes six hours (because) the doctors take care of the ones that are life-threatening first then we get to you.”

“This process can get you in and out of the system much more quickly,” Akif said.

“The flow has been a lot better,” Gray said. “They’re getting medicated faster. They’re getting their CTs quicker. By the time they get back to a room the doc really just has to do a disposition.”

“Where we seeing the most benefit is in the low-acuity cases,” Gray said. “Having the provider in triage to see patients with ankle sprains, simple lacerations… it has been an hour, an hour-and-a-half, that people are being discharged with those lower acuity things.”

Some hospitals have gone away from having emergency physicians on-site, not Warren General.

“All of our physicians in the ER are board-certified emergency medicine physicians,” Allen said. “Not a lot of rural community hospitals that have that. There are some critical access hospitals that only deliver care through nurse practitioners. We always have a board-certified emergency medicine physician on staff, on-site.”