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Creative space use slashes wait times
Interdisciplinary team also advised process changes
Unless your ED is planning an expansion, the amount of space you have to work with is finite. However, as the leadership team at Jersey City (NJ) Medical Center has shown, creative use of that space can significantly improve your department's capacity and help slash wait times and the number of patients who leave without being seen. In less than a year, average wait times went from 3-4 hours to 30 minutes, and the left without being seen (LWBS) rate went from 6% to 1.5%.
Last year the ED, which was built to accommodate 55,000 patients, saw more than 77,000.
"One of the biggest changes we made was to take a two-bedded room, remove the stretchers, and convert it to a six-patient room by putting treatment chairs in that area," recalls nurse manager Christy Wade, RN, MSN. She explains that if there was a patient on a stretcher who was not quite as acute as others but too sick to go to fast check or express care, they would go to this room. This gave the ED six more stretchers to work with.
Michael Bassette, MD, FACEP, the ED medical director, says, "It became sort of a pre-discharge area."
Wade says the staff also took some of the cubicles, and wherever there were two beds they would split them up into three during peak times. Extra set of tracks were added for the dividers that would be used at such times, she explains. "We could clip them on a little hook in the back when we were not using them," Wade notes.
So, at 11 p.m., when the ED normally experiences a surge, these become "split cubicles." The new set of curtains is pulled forward, and splitters are brought in for oxygen and other supplies. "It really works well. We get people out of the hallway beds," says Wade. "It's a bit tight, but the doctors are much happier to see the patients have more privacy, and the patients are also happier with that privacy."
Process changes also have contributed to the improved flow, Bassette adds. "We shifted to a lot more bedside registration and put an emphasis on direct bedding," he says. "Patients go from triage directly to the bedside." In addition to speeding flow, it reduces the likelihood of adverse events in the waiting area and gets the patients to the main treatment area, Bassette says.
Wade says, "If a space is available in the back, the patient will go directly to a bed and be triaged back there." She notes that there used to be a bottleneck up front while patients waited for triage and registration. The team set a goal of getting patients in a stretcher within 15 minutes, says Wade. "That greatly reduces left without being seen rates," she observes.
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Six Sigma team spurs improvement
A team that included radiology, the laboratory, housekeeping, patient access, EMS, and case management staff who were Six Sigma black or green belts led the way to process improvements that help slash average wait times from 3-4 hours to half an hour in the ED at Jersey City (NJ) Medical Center, says nurse manager Christy Wade, RN, MSN.
"On the original team, they all were certified," Wade says.
Michael Bassette, MD, FACEP, the ED medical director, notes that this project was part of their green belt certification.
Wade says the staff was included in the whole process. "We invited them to a meeting when we started to roll the program out, and they helped us figure out how to do it," she says.
She notes that this effort is all part of the Six Sigma "voice-of-the-customer" approach. "We interviewed the staff, asked what they needed and how it could be done," Wade says. "That increased buy-in."
'We were able to pull tons of data'
The process of identifying opportunities for improvement was made easier by the EDIMS (Emergency Department Information Management System, edims.net) computer system in the department, she says. "We were able to pull tons of data on all points along the visit – and daily, weekly, and monthly throughput numbers," Wade says. "We could identify where the bottlenecks were and what slowed us down. We could even figure out what time of day or day of the day of week they occurred."
The key to ongoing success was transforming the staff into champions of the project, Bassette says. "We would evaluate the system weekly with them," he says. "And when we saw standouts, we'd recognize them and reward them for that, and they became champions of the system itself."
The rewards were based on a system called "wild cards," which basically were acknowledgement cards that offered credit in the gift shop or cafeteria. "I send thank you cards every week to the particular standout of the week," adds Wade. "I send a note to their home, usually with a wild card tucked in." In addition, she says, when people are mentioned in the department's Press Ganey patient satisfaction survey, they are publicly acknowledged in a ceremony each month by the CEO.
Barrette says, "Now people are starting to acknowledge each other. Express care is open from 10 to 10, but the staff decided on their own to keep it open until midnight last night, and they ended up keeping it open until 3 a.m."