Nurse Manager's Project Increases ED Capacity

Christy Wade became nurse manager of the emergency department at Jersey City Medical Center two and a half years ago and faced a problem shared with EDs around the country: too many patients and too little space.

In 2009, the urban, level two trauma center saw 77,000 total visits in a space designed for 50,000. The high volume resulted in wait times averaging 3-4 hours, frequent need for diversion, and more than 6% of patients leaving without being seen.

Wade and her colleagues—all Six Sigma certified—searched for ED bottlenecks and ways to remove them. The interdisciplinary team included representatives from every area that interacts with the ED, such as housekeeping, radiology, etc. They instituted changes, including a new approach to observation patients, that have reduced wait times to an average of 30 minutes, and decreased hours on divert to zero. Last month less than 1.5% of patients left without being seen.

When they started the project, the ED began to use an EDIMS computer documentation system, which allowed the Six Sigma team to collate necessary data. "We could pull data in such a way that we could see where our bottlenecks were," says Wade. "We could see where we needed to focus for throughput. One of biggest problems was that we just didn't have enough space."

The team changed the way the ED uses it space. A small room that was being used as a chest pain observation room was converted to space for six or more observation patients.

"The room had two cardiac monitors, two beds. It was not the best use of space," says Wade. "So we removed the stretchers and lined the room with big comfortable treatment chairs."

Now patients who have been seen in the ED and who are under observation or are waiting for something fairly simple can relax in one of the treatment chairs, watching a flatscreen TV, rather than taking up an entire cubicle.

"Let's say someone just needs blood work," says Wade. "They're too sick to go over to our fast track area, but not sick enough to take up a bed. Now they can sit in these comfortable Barcalounger things and watch TV. It frees up valuable stretcher space for acute patients."

The room still houses two beds during quiet times in the ED, but around 11 a.m., when the ED starts to see more patients, the room is quickly converted with the treatment chairs to accommodate more patients. Wade notes the room still contains a stretcher in case a physician needs to reexamine a patient.

Dividers have been added to treatment cubicles for times when the ED gets even busier. "We have fairly big stretchers, so we took two stretcher spaces—two cubicles—and put dividers in, so can make a two cubicle space into three at busy times. And we can quickly convert back when needed," Wade says.

The computer documentation system allows Wade and the organization to keep close eyes on throughput and anticipate when they will need to extend high-capacity hours.

Wade says the changes have increased satisfaction of both staff and patients. "The word is getting out that waiting is decreasing, so our volume is increasing," says Wade. "And we're still able to cope with it. [We recently] had the busiest day in the history of our hospital."