Want to keep patients flowing out of the waiting room? Don’t have chairs

To ease overcrowding, offer alternative locations, push primary care

Encouraging patients not to come to your ED? Building a new ED with no waiting room? These are among the creative, and perhaps controversial, strategies adopted by two ED managers determined to address surge capacity in new and more effective ways.

At Lenoir Memorial Hospital in Kinston, NC, the ED ran a billboard that essentially said, "If you have a primary care physician, see him or her first," as part of an ongoing campaign to educate the public about what should and should not be considered emergency care. Lenoir also added a medical unit from which it could monitor patients remotely.

At Ball Memorial Hospital in Muncie, IN, a spanking new ED opened minus a traditional waiting room. The walk-in entrance resembles a small hotel lobby, minus the chairs. Patients are escorted immediately to a private room and registered at the bedside. These strategies have paid off. At Lenoir, "since these went into effect, on a routine basis, we do not hold patients," says Christina Miller, RN, the ED manager. And at Ball Memorial, length of stay has been reduced by 30 minutes — for general and for fast-track ED patients.

Encouraging informed decisions

Miller emphasizes that the main message at Lenoir was not "Don’t come to the ED." Rather, she says, "We wanted to give people the opportunity to make informed decisions about their care; people were using the ED for primary care treatment."

During the high-census months of December 2003 and early 2004, "We were having some difficulty with holding patients for admission, especially when we were overwhelmed [with overcrowding] on a routine basis," she says.

In the spring, months before the billboard appeared, articles ran in the hospital’s quarterly publication, Medlines, in which, Miller says, "We took a huge stance to educate people about what’s appropriate for ED care." In addition, there were postings in the hospital about limiting visitors and a monthly insert in the paper targeting key health issues. "In all of them, we always put out what is appropriate for the ED — especially [when we were] in high-census mode," she stresses.

Then, as flu season approached, the billboards appeared. They read: "Flu is in the ED: See your doctor." That terse message was fleshed out, however, in Medlines articles and in the other marketing vehicles used by Lenoir, including TV interviews with hospital representatives.

"The overall message was not Don’t come here,’ but rather, If you have symptoms, there is help available; go see your physician,’" Miller explains. "[The physician’s office] can be much safer — in our environment, there are a lot of very sick people — and there may be a longer wait."

The publicity campaign also informed patients who did not have primary care physicians, but who had primary care needs, that the ED had "Express Care" service available. "We are a 23-bed ED, with six dedicated to express care patients — people who would normally go to primary care, with colds, sinus infections, twisted ankles," says Miller. "We can fast track these patients with a turnaround time of 90 minutes."

The other key strategy employed at Lenoir was the additional medical unit. "We had the ability to monitor patients in the ED, but it became a huge customer service issue when patients had to wait four to five hours, or even overnight, for a bed," she adds. So the hospital managers held a cross-organization discussion and decided to open a medical unit that would have remote monitoring capability for patients waiting for admission.

"It was in an area of the hospital that was not being utilized; the beds had been licensed for long-term care beds," Miller recalls. "Through a certificate of need, we could open [the new unit] with the existing beds." The unit started with 15 beds, with more to come, and it has six or seven monitors.

Addressing satisfaction and overcrowding 

The unique design for the Ball Memorial ED was not only an attempt to improve patient flow, but also to enhance patient satisfaction.

"In the original meetings with the architects, we had a traditional waiting room in there," says Karla Kirby, RN, ED administrator. "But when we made a presentation to the CEO, he challenged us to think differently about the patient and family experience — to look at our service in terms of the patient, and not what was most convenient for the staff."

The new ED, which has been in operation a little more than a year, works like this: When the patient comes in, a quick-sort triage is performed. "An RN who is trained to be a triage nurse talks to the patients fairly briefly about what brought them to the ED," Kirby explains. "They take their name and birth date, put [the information] on a [computerized] tracking board, and the patients are escorted to a room." (For information about a virtual tour of the new ED, see the resources, below.)

Meanwhile, the tracking board is monitored by ED registration staff. "Whenever they see a patient on there, they do a quick admission," she notes. That quick admission allows the ED to have an account number, Kirby adds. "If they have been in here before, they already have one, so we can do the admission immediately," she says.

The patient is registered at the bedside. The registration clerk goes to the room, monitors the information already in the computer, and then takes the patient’s financial information.

The ED is subdivided by acuity, Kirby observes. "Essentially, we have an area of the ED where we take care of minor illness and injury: a fast-track area with designated rooms," she says.

Kirby likens the overall process to a tollbooth area of a turnpike, where a special express lane is set aside for automobiles with prepaid stickers on their windshields that are electronically registered as they whiz by. "This is kind of the same thing; instead of stopping to pay the toll, the patients are just slowing down a little bit at triage, then moving quickly to a room and through to care," she declares.

It has clearly had an impact on throughput. "Over this year, we’ve been able to cut 30 minutes out of throughput to fast track; we now run about 90 minutes," Kirby reports. "For regular patients who are discharged on the other side, we have also cut 30 minutes — down to 163."

As for patient satisfaction, the new ED has paid dividends as well. "The patients are highly satisfied; the difference is dramatic," says Kirby. "We use Press Ganey [to measure patient satisfaction], and prior to the move, we were never above the 50th percentile. Now, we are running in 80s and 90s."

Patients are giving staff positive comments about the new no-waiting room ED "all the time," says Kirby, and adds she’s not surprised. "One of the things we know is that people hate to wait," she says. Waiting rooms are unpleasant places, especially in an ED where people are sick, hurting, bleeding, and vomiting, Kirby says.

"We thought if we used the space normally allocated for a waiting room for more patient room, when the patients arrived they could get to the rooms more quickly, it would be more satisfying for the patients, and they would also be spared the unpleasant parts of the waiting room atmosphere," she says.


For more information on strategies to address surge capacity, contact:

  • Karla Kirby, RN, ED Administrative Director, Ball Memorial Hospital, 2401 University Ave., Muncie, IN 47303. Phone: (765) 747-3287. E-mail: kkirby@chsmail.org.
  • Christina Miller, RN, ED Manager, Lenoir Memorial Hospital, 100 Airport Road, Kinston, NC 28501. Phone: (252) 522-7933. E-mail: cmiller@lenoir.org.

For a virtual tour of the new ED at Ball Memorial, go to www.cardinalhealthsystem.org. On the left-hand side menu, click "ED," and you will be asked if you wish to take a virtual tour.