Consultant, more staff lead to ED turnaround

Door-to-doc time drops 1 hour 20 minutes

One year ago, the waiting room situation in the ED at Cape Fear Valley Medical Center in Fayetteville, NC, was "a sinking ship," according to John Reid, MD, chairman of emergency services. "It took 12 hours at least to get [an admitted patient] upstairs," he recalls. In just one year, the department has made the following improvements:

  • The total time patients who were admitted to the hospital stayed in the ED went from an average of 7.7 hours in November 2006 to 5.5 hours in November 2007.
  • The percentage of all discharged patients who were seen in less than four hours averaged 64.2% in November 2006. In November 2007, it was 79.3%.
  • The percent of patients who left without being seen (LWBS) was 5.8% in November 2006. In November 2007, it was 2.1%.
  • The average length of stay (LOS) for all discharged patients was 4.03 hours in November 2006. In November 2007, it was 3.02 hours. The goal is 2.5 hours.
  • The door-to-provider time was over two hours in January 2007. In January 2008, it was about 40 minutes.

Key process improvement changes were made at the recommendation of Richmond, CA-based EMPATH Consulting, a hospital consulting firm. In addition, 10 new ED doctors were hired.

'Dysfunctional' front end

The front end was very dysfunctional, says Linda K. Dietterich, RN, MS, CEN, CAN, service line director for the ED.

"All the patients would come in and line up in front of the intake nurse, who would just write down their complaint," she says. They would wait for registration without having been triaged, Dietterich says.

Another major bottleneck was the way they were triaging ambulance patients, adds John Backus, RN, BSN, clinical director of emergency services. "We would receive several in an hour and up to 100 a day," he says. The past practice was for the lead charge nurse to perform triage on EMS arrivals, which created delays in ED bed assignment/primary care nurse assignment, Dietterich explains. "This process would take up to 60 minutes to complete from patient arrival to ED bed assignment," she recalls.

Recognizing the seriousness of the problem, the ED management team determined outside help was needed. After convincing the administration to invest $2.6 million, they hired EMPATH in January 2006. "Some of our team went to Sacred Heart Hospital in Spokane [WA] with EMPATH and saw with their own eyes that the processes really did improve throughput," says Dietterich. In October 2006, the team from EMPATH began a 62-month on-site improvement process.

They changed the whole front-end process, Dietterich recalls. A greeter, or guest services representative, provides initial contact to all incoming patients and visitors and serves as a liaison between the visitors, patients, triage nurse, and ED lead charge nurse. "Our access representative does a 'quick reg.' to get their name in the system, and then they go right to a triage nurse," says Dietterich, who adds that this process has cut triage time in half.

Also, EMPATH recommended the concept of having teams, with each team having a doctor, a nurse, a technician or paramedic, and a unit secretary. That concept has improved other processes, such as ambulance receiving. It begins with the EmSTAT informatics, from Chicago-based Allscripts, recommended by EMPATH. Information about incoming patients goes right into EmSTAT, and the lead charge nurse assigns them to a zone, Dietterich explains. "They never even see the lead charge nurse because everyone knows where they are going," she says.

With the team concept, EMS calls about patients coming in via ambulance. Once the lead charge nurse designates a zone, the team leader in that area manages the placement and assessment of the patient, Backus says.

Getting more doctors

In addition to convincing administration to invest in EMPATH, Reid also had to sell them on hiring more staff.

"We did not have enough physician staffing, but it was a tough sell," he admits. "I did not give them a price tag, but instead focused on quality. Our 2006 volume was 90,000 and we did not have anywhere near enough docs."

The selling points centered on the ED's increased volume and the staffing models at other EDs with similar volumes, Reid says. "In addition, we had [physician assistants] seeing a lot of sick people, so it was a patient safety and quality issue as well," he says. He gained the board's blessing to hire 10 new board-certified physicians.

In addition to speeding processes and improving care, the new systems and additional staff have had a positive impact on patient satisfaction, says Dietterich. "It's been huge," she says. "In July 2006, we were in the ninth percentile, and now we are hovering around the 79th." In the middle of a recent quarter, she adds, the department hit the 99th percentile. "Just to get in the top quartile and be able to sustain that was amazing," she says.

Dietterich says the department has maintained top quartile ranking percentile (82%), as benchmarked with EDs that have more than 70,000 visits per year by patient satisfaction firm Press Ganey. "Currently, year-to-date patient satisfaction ranking in our ED, is at the 92nd percentile," she adds.


For more information on streamlining front-end processes in ED, contact:

  • Linda K. Dietterich, RN, MS, CEN, CAN, ED Service Line Director, Cape Fear Valley Medical Center, Fayetteville, NC. Phone: (910) 609-7891. E-mail:

For more information about ED process improvement, contact: EMPATH Consulting, Richmond, CA. Phone: (888) 436-7284. E-mail: Web:

For more information on EmSTAT ED informatics, contact: Allscripts in Chicago. Phone: (800) 654-0889. Web: