Emergency department decreases 4-hour wait times to 9 minutes

Rapid evaluation unit model was most important driver

Not long ago, the ED at Palisades Medical Center in North Bergen, NJ, was struggling with waiting times hovering at about four hours. "Like every other ED, we struggled with long waiting times — especially on the 3 to 11 shift," recalls Maureen Coccaro, MS, RN, one of two clinical coordinators of the ED. "If you had six people come in at once, with the old traditional approach it would take a nurse 10 minutes to triage each patient, so the last person to arrive would be waiting an hour."

The ED, which sees 35,000 patients a year, replaced that "traditional" approach with a rapid evaluation unit model. The results? Door-to-doc time is now at around nine minutes. "We still do triage, but we have brought it to the bedside," she explains. "That has freed up the front end."

When a patient first arrives at the ED, he or she now is met by a greeter, who is a clerk and will perform a quick registration. That registration gets the patient into the medical records system. The greeter then will bring the patient into the rapid evaluation unit and hand him or her off to a nurse. The patient is triaged at the bedside by a nurse, a physician's assistant, or a doctor.

"This gives us the opportunity to order whatever the patient needs then and there," Coccaro says. For example, there is no wait for the lab to pick up the blood. Lab work is sent via a newly installed pneumatic tube. Gladys Sillero, MSN, RN, CNS, APN-C, clinical nurse specialist and the other clinical director of the ED, says, "Some of our nurses' aides were educated in how to draw blood and they are nurse technicians now, so we can do bedside tests like glucose levels."

Coccaro says, "We can also discharge the patient with instructions more quickly, since we have a nurse both on the front end and at the back end." In spring 2008, the hospital started looking at processes and how the staff could better flow patients, Sillero says. She notes that hospital and ED leadership approved the hiring of a consultant from Woodbury, NJ-based Emergenuity, to work with the ED.

In addition to the rapid evaluation model, says Sillero, the consultant recommended dividing the ED into two areas: one for walk-ins and low-acuity patients, and the other for those who required a full work-up. "The patients are usually admitted from that area," she explains.

Furthermore, the ED staff members have been communicating with the other departments about their work flow and how it affects the ED, Sillero says. "We've started doing morning rounds and getting together an interdisciplinary team to expedite care and discharge patients more quickly," she says. "I think it has helped a lot." Sillero says the team includes herself and Coccaro, a charge nurse, other nurses, physicians, physician assistants, ED techs, nurses' aides, a social worker, and a case manager.

While the ED staff agree that the installment of a rapid evaluation unit model was the major reason they were able to get door-to-doc times down to nine minutes, they note that smaller, less "glamorous" changes also made a significant contribution to their success.

For example, "We had just done over the back part of the ED to assist us with flow," says Coccaro. A discharge area was created and equipped with "stretcher-beds," a TV, and magazines so that patients waiting for X-rays or discharge instructions did not have to wait in the patient care area. Those beds could be used by new patients.

Coccaro says additional flow time was freed up with another simple change. "Before, every patient was brought in on a stretcher," she notes. "Now, they are brought in on a stretcher only when it's necessary. We have comfortable chairs for people with less serious illnesses or injuries to sit on."

When all patients were brought in on stretchers, they were also all put into hospital gowns, which took time, "and many patients do not need all that," she says.

Sources

For more information on rapid evaluation units, contact:

  • Maureen Coccaro, MS, RN, ED Clinical Coordinator, Palisades Medical Center, North Bergen, NJ. Phone: (201) 694-6159.
  • Gladys Sillero, MSN, RN, CNS, APN-C, Clinical Coordinator, Palisades Medical Center. Phone: (201) 854-5761.

D-to-D improved — It's on to LOS

Not content with slashing wait times from over four hours to about nine minutes, the ED staff at Palisades Medical Center in North Bergen, NJ, is redoubling its focus in another area: length of stay.

"We are at four hours, or a little below, and we're working to get it down to three," says Maureen Coccaro, MS, RN, one of two clinical coordinators of the ED.

Gladys Sillero, MSN, RN, CNS, APN-C, clinical nurse specialist and the other clinical director of the ED, says, "At one point, it was greater than five hours. At most hospitals, four to six hours is the norm."

In addition, Coccaro says, "We just put in a new documentation system for both doctors and nurses." The Picis ED PulseCheck system is manufactured by Wakefield, MA-based Picis (www.picis.com). "It's relatively new, but what we're trying to do is improve patient safety by eliminating legibility problems associated with handwriting, and also ensure better flow while the patient is in the ED," she notes.

Coccaro is convinced staff resistance will not be a problem as changes are made. "People do not like to change from old modalities," she concedes, "But we have a mixture of seasoned and younger staff, and they have worked together well as a team."


Clinical Tip

Don't overlook need for accurate history

Even if you are performing just a quick triage, you always need to make sure you listen to the patient and obtain a thorough and accurate history, advises Maureen Coccaro, MS, RN, clinical coordinator of the ED at Palisades Medical Center in North Bergen, NJ.

"The patient is always the best historian, and you can never let that go," she says.