A Faster Emergency Department in Five Days

In 2009, Press Ganey found that ED turnaround times still average over four hours, basically unchanged over the last decade. In 2006, the Centers for Disease Control and Prevention (CDC) found that 40 percent of hospital EDs were overcrowded. One Harvard study found that ED wait times rose 36 percent from 1997 to 2004.

Robert Wood Johnson Hospital in Hamilton, New Jersey (RJW), winner of the 2004 Baldrige Award, receives 50,000 patients a year. In 2004, RJW had ED turnaround times of

• 38 minutes for discharged patients
• 90 minutes for admitted patients

How is this possible? How did they do it? By systematically eliminating the delays between registration, triage, examination, lab, imaging, and discharge or admission/transport.

RJW’s 15/30 Program

In 1998, RJW offered a 15-minute door-to-nurse and a 30-minute door-to-doctor guarantee. Like Domino’s Pizza, if your nurse or doctor is late, your service is free! Patient satisfaction with the ED rose from 85 percent in 2001 to 90 percent in 2004. While payouts for this policy have been less than 1 percent of ED patients, ED visits doubled! This means that for 1 percent of the revenue, RJW increased ED revenue by 99 percent.

And because ED visits doubled, hospital revenue increased as well. Seventy percent of hospital admissions come from the ED. Faster turnaround times enabled the hospital to grow by over 10 percent per year, requiring the addition of a new nursing wing.

Results

• RJW was New Jersey’s fastest-growing hospital from 1999 to 2003.
• Mortality rates for patients with congestive heart failure (CHF) declined from 8 to 2.5 percent.
• Infection rates for things such as ventilator-assisted pneumonia (VAP) fell from 10 per 1,000 vent-days to only 2 per 1,000 vent-days.
• The cardiology market share rose from 20 to 30 percent.
• The surgery market share rose from 17 to 30 percent.
• Hospital occupancy rose from 70 to 90 percent.
• Employee satisfaction with benefits rose from 30 to 90 percent.
• Employee satisfaction with participation in decision making rose from 30 to 90 percent.
• Retention of nurses rose to 98 percent.
• Employee retention rose from 80 to 98 percent.

Faster patient flow means greater patient satisfaction, better outcomes, and more money!

Studies have shown that patient satisfaction begins to decrease when ED LOS exceeds two hours. There are two populations of patients who visit the ED, so let’s separate the emergent from the nonemergent cases and look at patients who get discharged.

If it takes only a couple of minutes to see the triage nurse, a few more minutes to get registered, and a few more minutes for a doctor diagnosis, then the total time spent on any one patient is perhaps nine minutes. So why does it take most EDs over two hours to handle each patient? Sure, some patients need lab work (11 minutes) and others need radiology, but most of those tests take less than an hour. We’re still looking at 35 to 60 minutes, not two hours or more.

If we look at admitted patients, they are taken into the ED immediately without having to wait. They see the doctor immediately. Tests are done STAT. Registrations are done at the bedside. Nursing floor bed assignments take only a few minutes. Nursing reports are fast. Transport to the intensive care unit (ICU), cardiac care, or Med/Surg floor takes only 15 to 20 minutes. These patients should fly through the ED, but they take longer than the discharged patients—two to three times longer. Sure, they have to be stabilized, but why does it take hours to get them into an assigned bed?

The answer, across the board, is delay. There is too much time between activities. The admission staff is busy, so patients have to wait. The triage nurse is busy, so patients have to wait. The ED is boarding patients who should be in a nursing unit, so patients have to wait. The ED nurse can’t reach the floor nurse to give a report, and vice versa. Neither nurse can leave to transport the patient. Beds are available but not staffed. And so on.

Imagine a Faster ED

Imagine an emergency room where patients walk in and something surprising happens:

1. They use the magnetic strip on their driver’s license, insurance card, or credit card to check in and register using a kiosk. The kiosk automatically takes pictures of all these IDs and uses the data to find the patient’s medical history, validate insurance, and so on.
2. Completing registration this way triggers a “pull” signal that brings the next nurse in the queue to collect the patient from the entry area and move him or her to an exam room.
3. Entering the exam room and gathering the patient’s vital signs triggers a pull signal for the next ED doctor in the rotation.
4. The doctor examines the patient with the nurse available and requests any tests or x-rays using a handheld device that kicks off the orders.
   1. The nurse draws any blood or other samples required and either (1) sends them to the lab for processing or (2) uses point-of-care testing to get results in 11 minutes or less. (Approximately 70 percent of patients require lab work.)
   2. The nurse transports the patient to imaging, if needed. (Approximately 30 percent of patients require medical imaging.)
5. Completion of the tests triggers a pull signal to the ED doctor to collect the results, diagnose, and recommend treatment.
6. The doctor then initiates treatment. Any “teaching” material or paperwork required is prepackaged and ready for the nurse to prepare the patient for discharge or admission.
7. Initiating admission kicks off a pull signal for a bed in the appropriate unit. If there isn’t enough staff in that unit to handle the admission, a pull signal may request an on-call nurse to come to work.
8. Instead of all being done manually, as most of this is now, it’s all carefully orchestrated and technically linked to minimize delay. Many of these activities can happen in parallel, not sequentially as they do today.

A discharged patient is in and out in 30 minutes. An admitted patient is in a nursing unit bed in 60 minutes. Of course, there will be exceptions—a rush-hour accident may tie up one of the doctors—but most patients are discharged. Finding ways to handle them in “one-piece flow” will improve ED performance dramatically.

Simply speeding up discharge and housekeeping of nursing unit beds can alleviate boarding and overcrowding in the ED. Empowering triage nurses to order x-rays for possible fractures without doctor involvement can accelerate diagnosis and treatment. Scheduling radiologists during the hours of highest trauma injuries (think rush hour and Friday/Saturday night) can accelerate ED throughput. Prepackaging common triage kits can accelerate treatment.