Multifaceted approach keeps patients flowing

Busy ED has door-to-doc time of 40 minutes

The ED at Middle Tennessee Medical Center (MTMC) in Murfreesboro certainly qualifies as busy: it sees nearly 63,000 patients a year and averages more than 170 patients a day. Yet the average time it takes a patient to get to triage from entry into the ED is 14-17 minutes, and its door-to-doc time averages 35-40 minutes. The department leadership says its success is due to the ongoing pursuit of process improvement, often with several initiatives under way at the same time.

"It's a multifaceted approach," says Kevin H. Beier, MD, FAAEM, a physician in the ED. "We have a relatively small department for this volume."

Monty Gooch, RN, BSN, director of emergency services, says, "Our initiative to look at [patient flow] has been ongoing." Here are some of the more recent initiatives in the ED at MTMC:

  • a lab phlebotomist hired specifically for the ED;
  • the hiring of additional ED physicians;
  • the expansion of point-of-care testing;
  • the installation of a Lifenet Receiving Station. This collaborative effort with the Rutherford County Emergency Medical Service enables the staff to receive wireless EKGs from the field.

The ED staff response to the patient demand is extremely flexible, notes Beier. During heavy volume times, when they have 20-30 patients in triage, they use parallel assessment, he says. "We do the patient assessment right away in triage, order testing, and expedite their testing instead of them waiting three hours in triage to be seen," he says. Instead of having the nurse triage the patient up front, he says, the patient is brought back and triaged by a nurse and physician, which expedites testing orders.

They make extra efforts to pull patient into the back from triage, Beier says. "We do what we can to reduce the roadblocks to getting patients through the department."

Perhaps the initiative with the greatest immediate impact was the Lifenet station. "The county EMS initiated the program," says Gooch. "We had to buy the software program, plus a tabletop computer." The LifeNet Receiving station was purchased through an $11,998 grant from the MTMC Foundation, a nonprofit corporation based in Murfreesboro (

"It has significantly improved MI care," adds Beier. "We can call the cath lab and cardiology at the same time, and sometimes we are able to have a cardiologist in the ED before the patient arrives." The hospital added an interventional cardiologist about six months ago, he notes. "Many of our patients that we would have transferred out, we now keep on site," Beier says. The cardiologist's office is directly across from the ED.

Before the installation of the Lifenet station, says Gooch, door-to-balloon times were about 123 minutes, or above the nationally recognized standard of 90 minutes. "Last month, we were at 68 minutes," he reports.


For more information on improving ED patient flow, contact:

  • Kevin H. Beier, MD, FAAEM, ED Physician, and Monty Gooch, RN, BSN, Director of Emergency Services, Middle Tennessee Medical Center, Murfreesboro. TN. Phone: (615) 396-4100.

For more information on the Lifenet Receiving Station, contact:

  • Medtronic, 710 Medtronic Parkway, Minneapolis, MN 55432-5604. Phone: (763) 514-4000. Fax: (763) 514-4879. Web: