ED pledge: See doc in 30 minutes or visit is free

Hospital has canceled only 27 bills in 3 years

You say you want a revolution in your emergency department? Then consider this pledge: At Robert Wood Johnson University Hospital in New Brunswick, NJ, patients see a nurse within 15 minutes or a doctor within 30 minutes or their visit is free.

In the three years since the guarantee was implemented, the hospital has canceled bills for 27 out of 156,000 patients. Sixty-four percent of patients are now treated and released from the emergency department in less than two hours, compared with 40% before the guarantee was implemented. Walk-outs have been virtually eliminated.

And not only that, but the hospital, which is a Level I trauma center, has dealt with a 20% increase in visits to the emergency department, ostensibly resulting from an orchestrated marketing campaign including TV and print ads to attract more customers. The effort has been so successful that in September, the pledge was adopted by four more hospitals in the Robert Wood Johnson Health Network. The remaining two hospitals in the network will bring the pledge on board by March. In the first month, the network's ED volume increased 11% and bills were canceled for 23 patients among all five hospitals, says Andrew Greene, the network's CEO. "That was less than 1% of the patients seen," he says. "It's remarkable when you see how different all the hospitals are: They're in urban, suburban, commuter settings. It can work anywhere where there is a serious commitment to the program."

The guarantee grew out of an initiative to reduce waiting times in the ED. Harvey A. Holzberg, president and CEO of Robert Wood Johnson University Hospital, says the issue came up in regular meetings senior staff conduct with primary care physician groups. "They told us they hesitated to send their patients to our emergency department because the wait was so long," he says.

The hospital had already begun responding to long ED waiting times through a 1993 renovation that doubled the size of the department and created specially equipped trauma, critical care, and cardiac treatment rooms as well as a seven-bed chest pain and holding unit. A "fast track" area was set aside where walk-in patients with relatively minor problems such as sprains, fractures, earaches, and the flu are seen by a separate staff of emergency physicians and pediatricians. The renovated department also includes a dedicated radiology suite so X-rays can be taken and read in the ED.

Those changes had led to an average waiting time of 30 minutes, but because public perception that nontrauma patients had to wait forever remained, Holzberg challenged the staff to make the actual waiting time 30 minutes. "The patient who waits two hours doesn’t care that someone else only waited five minutes to produce an average of 30 minutes," he says. "For some patients, our customers, their experience in the emergency department may be their sole encounter with Robert Wood Johnson University Hospital. They expect the highest quality medical care, and they receive it. But what they remember is whether we paid attention to the urgency of their concerns."

One of the initial problems the staff faced with the guarantee that a nurse would see patients in 15 minutes was that the initial registration process alone took 15 minutes to complete. So the first change made was to cut the paperwork, says Anne Marie Keenan, RN, director of the ED. "Now patients are seen first by a triage nurse who evaluates them, creates their chart, and immediately escorts them to the fast-track treatment area," she says. A registration coordinator follows patients and records their information while they wait for the physician. The chart stays with the patient, no longer waiting in bins to be picked up and processed independently at each stage of treatment.

Instead of hiring more employees to meet the guarantee, the hospital restructured its staffing. A dedicated pediatric nurse works from 5 p.m. to midnight, and two nurses are assigned at all times to triage at the ED entrance. Primary attending physicians work three eight-hour shifts and one 11-hour "fast track swing shift" from 11 a.m. to 10 p.m. They stay past the initial eight hours or come in early if demand is high. The supervising nurses restructured their schedules on an eight-hour rotation that changes one hour after the physicians’ shift change to ensure a smooth transition. The only staff position created was a part-time registration clerk.

Initially, there were disparaging comments comparing the focus on speed to pizza delivery. "But emergency department personnel choose to work in a fast-paced environment, and they like a challenge," Keenan says. "The staff were already doing a good job, and they wanted to be recognized for it. Now, they’ve done a remarkable job in creating a model program that sets an example for other hospitals."

For more information, contact Debbi Dunn Solomon, Public and Community Affairs Department, Robert Wood Johnson University Hospital, New Brunswick, NJ. Telephone: (732) 937-8519.