Tiered structure helps ED improve flow, satisfaction

Department cuts LOS 40 minutes

Between 2001 and 2005, average length of stay in the ED at Northwestern Memorial Hospital in Chicago has dropped from 85 minutes to 45 minutes. Throughput has fallen from 308 minutes to 230 minutes during the same period. In addition, patient satisfaction (Press Ganey Associates, South Bend, IN) scores have increased from 74.6% to 84%.

This improvement was due to a number of factors, notes James Adams, MD, chairman of the department of emergency medicine. For one, the department instituted a comprehensive Six Sigma initiative during that time period. But perhaps one of the most unique strategies, and one that has clearly had an impact on the aforementioned improvement, was the redesign of the ED management structure.

"We have four nurse managers, and each has a subsegment of staff and shifts," Adams explains. The new structure, he adds, was adopted in fall 2003. The nurse managers are assigned as follows:

  • There is a night manager who works 11 p.m.-9 a.m. four days a week.
  • There is another evening manager who works from 2 p.m.-midnight four days a week.
  • There are two day’ managers, one of whom manages the observation unit (OU) and also has ED staff, while the other works entirely in the ED. Both of these managers work 8 a.m.-5 p.m., five days a week.

Managers split responsibilities

Their managerial responsibilities are further divided, explains Deborah Livingston, RN, MS, director of emergency services. "We’ve taken major pieces of what managers do, like staffing, salary and budget, quality management, and equipment, and assigned those responsibilities to each of them," she says.

Salary, budget, and staffing are assigned to the night manager. Quality management has been assigned to the evening manager. Equipment is assigned to the day manager who doesn’t have the observation unit. The person who is upstairs with the observation unit and downstairs with the ED also manages staff educators, Livingston says.

They want to take advantage of efficiency in educational and orientation opportunities upstairs and downstairs, she adds. Why run two programs when you only need one?"

These responsibilities were assigned based on expertise, Livingston says. "We put a person who was incredibly meticulous with salary, budget, and staffing," she says. She also has a scheduler who works with her, Livingston notes. "We have quality nurses in the department who work with the quality manager," she says. They do all the callbacks for left without being seen (LWBS), radiology callbacks, and nurse quality data collection.

Double-duty’ valuable

The assignment of a single manager for the observation unit and part of the ED staff was an extremely important part of the improvement process, says Livingston. "It really helped us make initiatives between the two areas flow better, as she has staff and influence in both areas," she says. "It’s a big part of why we have been so successful."

Once example is the "orange," or middle triage patients. (Northwestern has a five-level, color-coded triage protocol.) "These are mostly young, otherwise healthy patients with abdominal pain who would normally wait the longest," says Livingston. They often need a lot of tests and scans, she says.

The patients who go from the ED waiting room to the observation unit go there for their ED care, Livingston explains. "We call it ED2,’ she says. "We have an emergency room attending up there at all times these patients are up there. They are registered as ED patients with a special code that denotes their different location." This change starts to drive the culture that patients should not wait, Adams says.

After they have received their ED evaluation and care, if they need observation care, they then are admitted to the observation unit for outpatient observation. They stay in the same room and bed. The patients are happy, as they avoid long waits in the ED and they have a bed and a TV, says Livingston.

Inpatient holding patients (select admitted patients waiting for an inpatient bed) are also placed up in the observation unit. "This unloads the ED and improves throughput, so patients don’t wait as long to be seen," she explains, "With inpatient beds very tight, the [observation unit] is our most consistent outflow opportunity for the ED. We are creatively maximizing its use."

All programs affected

Livingston notes that the tiered structure not only directly impacts performance in the ED, but also contributes to the success of specific Six Sigma initiatives.

"It’s great to have more than one manager to work on these initiatives we are making," she says. "We always team a nurse manager with a physician, and this gives us more people to go around."

Personally, Livingston is extremely thankful for the new structure. "This would be a lot of work for one manager to be doing," she concedes. "It also helps the staff because they have a go-to person for whatever they need. It creates much less confusion about who is doing what."

Of all the improvements engendered by the new structure, the most important are those that impact wait times and throughput, Adam asserts. "Quality in the ED is time-based," he says.


For more information on a tiered ED staff structure, contact:

  • James Adams, MD, Chairman, Department of Emergency Medicine; Deborah Livingston, RN, MS, Director, Emergency Services, Northwestern Memorial Hospital, 251 E. Huron, Chicago, IL 60611. Phone: (312) 926-2000.