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Preview: The High-Performance Emergency Department

 |  By Jim Molpus  
   March 26, 2012

This article appears in the March 2012 issue of HealthLeaders magazine.

Editor's note: This piece is an excerpt of a fuller case study that is part of an upcoming Rounds event, Create Your High-Performance, Patient-Centered Emergency Department. To see the complete case study, which includes three additional lessons and more information, visit www.healthleadersmedia.com/rounds/.

The emergency department at Cambridge Health Alliance's three EDs used to be like Disney World, and not in a good way, says Assaad Sayah, MD, chief of emergency medicine and president of the medical staff. It went like this:

Wait. Wait. Wait.

Go for a short ride.

Wait. Wait. Wait.

Go for a short ride.

The herky-jerky flow of many, if not most, American hospital EDs is the natural by-product of their structure, Sayah says.

"Historically, when patients go to emergency departments, they walk in and they're confused," Sayah says. "There's nobody to talk to them. At some point somebody recognizes they're in the emergency department and then the patients go into triage. They spend time in the triage and then they go back to the waiting room. Then they go into registration after a while. Then they go back into the waiting room, and then at some point they make it inside the ED."

Sayah and his team did a top-down assessment of the ED flow and found multiple bottlenecks at CHA's three Massachusetts EDs in Cambridge, Somerville, and Everett, which together saw 96,712 ED visits in FY 2010 and 97,381 ED visits in FY 2011. It was not an ED capacity problem, they found, as there was plenty of ED bed capacity. Too many steps were happening consecutively that did not need to. CHA undertook a reengineering of its patient flow process, resulting in huge improvements in patient satisfaction and other key metrics in just six months.

The first step was eliminating traditional triage and registration. CHA hired "patient partners," multilingual nonclinicians whose role is to greet ED patients when they walk in the door and collect three pieces of information: name, identifier such as Social Security number or date of birth, and chief complaint. Answers are entered by the patient partner into a "computer on wheels" and CHA's Epic-based electronic health record. The process takes approximately two minutes. "With those three questions, the patient is registered; they are in the computer, I can take care of them in the ED, and they're brought right in," Sayah says.

The next step is the merger of what used to be registration, triage, and what was called express care into rapid assessment. The patient partner brings the patient directly into a room in the rapid assessment area. The patient is seen by a nurse and usually an ED tech first, says Lisa Kingsley-Rocker, RN, BSN, emergency department nurse manager at CHA's Whidden Hospital campus in the densely populated, working-class city of Everett, adjacent to Boston. Triage ranks the patient according the AHRQ Emergency Severity Index score of acuity from 1 to 5, with 1 being the most acute and 5 the least.

While the less acute patient is in the rapid assessment room, the physician assistant orders whatever diagnostics need to be done.  While waiting for results of those diagnostics, full registration is handled. After the patient is treated by the PA or given a prescription, the nurse discharges the patient directly from the room. "The average length of stay for rapid assessment patients is slightly over an hour, door to door," Sayah says.

Patients who are assessed, treated, and discharged straight from rapid assessment make up approximately 40% of overall ED volume at Whidden. Two quarters after the rapid assessment program went live, overall ED patient satisfaction jumped from the 15th percentile to the 65th. Patients who left without being seen—a key metric for waiting room holds—dropped from a peak of 4.04% in 2006 to 0.68% in FY 2011.

Those with higher severity are taken immediately to the main ED where they are assessed and seen by the ED specialists for more advanced diagnostics and assignment to inpatient admission.   

CHA's new throughput process allows problems to be addressed with specificity and speed. "The ED tradition used to be one mighty river, so everybody came in and went through the same process," says Nancy Sears-Russell, RN, BSN, MS, associate chief nursing officer for emergency services. "Now it's many, many tributary rivers."

Luis Lobón, MD, site chief of emergency medicine at CHA's Cambridge Hospital campus, says physician-to-nurse communication was also a barrier to good patient flow and quality care when he arrived in 2007. Nurses would do assessments, only to hand off the patient to a provider who would most often see that patient independently.

"One of the practical things that I started to implement was to discuss the patients with my nurses," Lobón says. "As simple as that may sound, that was something that was unheard of." Lobón knew there was an issue when he showed up during the nurse triage on a patient and she asked, "Are you going to be with me in the room? I'm not used to that." When he would share his thoughts about the patient's diagnosis or treatment with the nurse, he would get another perplexed look. "They would ask, 'Why are you asking me this?' and I would say, 'Because we are working this patient together.' That concept did not exist. It was huge, huge."

Rocker, the ED nurse manager, agrees: "There's a lot more communication and team effort. We huddle going in to take care of the patient. The physician is telling us what they think. They're very open to nursing suggestions and nursing assessment pieces to the patient condition. More often the physician and nurse are evaluating the patient together. It's not one against the other. We're not waiting." 

The ED transformation achieved another of its key metrics: zero, as in the amount of capital spent. All existing staff and space was reallocated.

"You work with whatever you can," Sayah says. "It's more of a function than a location or a physical plan." Part of the solution was as simple as replacing desks with beds in former registration rooms.

Additional lessons in the full case study are: Lesson 2: Fix the flow outside the ED; Lesson 3: Install leadership and compensation structures to build physician culture; and Lesson 4: Invest in the ED as a strategic part of integrated delivery enterprise.

Reprint HLR0312-10


This article appears in the March 2012 issue of HealthLeaders magazine.

Jim Molpus is the director of the HealthLeaders Exchange.

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