Rapid intake, empowered nursing staff energize no-wait ED model

Staff-driven solutions deliver high patient satisfaction

Getting an entire staff of physicians, nurses, and techs to do things differently is never easy, but you can clear away hurdles by giving them the ability to formulate some of their own solutions. That, at least, has been the experience of Swedish Medical Center in Issaquah, WA, in its quest to implement a more efficient, no-wait ED concept. The approach appears to be sitting well with patients, too. Administrators say that that the ED has been able to deliver on its no-wait promise in nearly every case, and patient satisfaction is greater than 95%, according to Press Ganey surveys.

Getting to this point involved a process of trial and experimentation that began with the opening of a free-standing ED back in 2005, explains John Milne, MD, MBA, the vice president of medical affairs at Swedish Medical Center, who oversees three of the organization's EDs, including the one at Issaquah. "That was the first step in a bridge strategy as we were building a new hospital in the community," says Milne, noting that he was one of the physicians who started the group that was staffing that ED, which has since closed. "The department we created there was in many ways a laboratory for a variety of things around efficiency, flow, and process."

Given a blank slate to work with, staff were empowered to tweak, tune, and manipulate the no-wait model. And a group of nurses, in particular, were highly motivated to come up with solutions, says Anne Neethling, RN, who managed the initial free-standing ED, but is now the nurse manager of the ED on the Issaquah hospital campus. "They were really fed up with the way regular or normal EDs worked, especially the long wait process," says Neethling. "They were given the opportunity to try out some new ways of doing this."

Opt for a rapid intake approach

The result of all this experimentation is a process that begins with a burst of activity as soon as a patient presents for care. "Any patients who come to the front registration desk provide three pieces of information: their name, their birth date, and another identifier. Then they get placed in a room right away, so nobody has to wait outside," says Neethling. "Then the process of triage, diagnostics, and treatment is started immediately, which has been a great satisfier for patients who are not used to this system."

Milne likens this phase of the process to the way pit crews service cars in the midst of a NASCAR race. "We refer to it as swarming," he says. "When a patient comes to a room, you've got the primary nurse who is taking care of him, but then a tech comes into the room, the charge nurse is there as another set of hands, and the physician is trying to get into the room as quickly as possible as well."

During the first five to 10 minutes, there may be as many as six people in the room tending to the patient during the initial intake event. "This ultimately frees up additional resources to move on to that next patient so that when a surge does happen, where you have one patient after another … you are moving faster, so on the back end it saves time in the sense that there is more capacity," says Milne. "The patient is out of the department sooner, so we have another room available."

There can be as many as three or four patient intakes going on at the same time, and by taking care of the diagnostics early on, patients move through the system swiftly, says Milne, contrasting the process with a traditional triage approach. "The concept of triage is essentially a misnomer. You basically have created a bottleneck choke point — a triage nurse or a triage entry point — which, from my perspective, adds limited value," he observes. "The highest-risk person is the one who is waiting in the waiting room, and we all hear stories of facilities where patients die of a heart attack in the waiting room after they have been sitting there for four or five hours after they have been triaged. Triage is not a perfect system, so the better choice, from our perspective, is to get patients back and evaluated, and have a rapid intake process."

Lose the 'hierarchical' structure

While most ED personnel are accustomed to working as part of a team, the approach developed at Swedish takes the concept to another level, essentially putting doctors, nurses, techs, and other personnel all at the same level, says Neethling. "There is no hierarchical structure," she explains. "Most of the time, this is done respectfully. Every now and then it doesn't go so well, but people talk to one another and they are able to depend on one another. That part of the culture is really the basis for this."

Neethling acknowledges that achieving this type of culture in a traditional hospital-based ED has been a much steeper climb than for a freestanding facility because it requires the involvement of many additional departments. "It has been quite a challenge for us, but we are getting there, trying to develop the same sort of teamwork with the inpatient hospital staff," she says.

One early step in the process was a one-day retreat for management staff, including leaders from radiology, the lab, and even primary care, in addition to the ED managers. This took place a few months before the ED at Issaquah opened, and it involved discussions about goals and expectations for the new facility. "Then about one month before the new ED opened, we had a three-day retreat that was targeted at the new staff who were coming in," says Milne. "Leaders from the first free-standing ED [to implement the no-wait process] participated, and there were panel discussions about what it means to be in startup mode, which is a little bit of a unique experience for health care personnel."

The retreat included several workshop sessions focused on customer service, and there were team-building exercises to get the staff accustomed to working with each other in ways that would foster the type of culture administrators were trying to infuse in the new ED. "By the time people began to move into the new facility, there was already a level of camaraderie that had developed out of these experiences," says Milne. However, he acknowledges that building a new culture requires a lot more than a three-day retreat. "It is a continuing, ongoing process," he says.

Listen to staff

In fact, Milne suggests that administrators are now grappling with the biggest challenge involved with implementing the new model: finding ways to sustain the initial vision, and to continue to empower staff to own their portion of the workflow. The burden of this task largely rests with managers, adds Milne, noting that it is not enough to hold a monthly staff meeting.

"Anne [Neethling] comes in early every morning and huddles with staff. She spends time trying to understand their issues while reinforcing the vision, and nipping in the bud any seeds of discontent," says Milne. "At the same time, the staff know she is an advocate for them with senior administration, even while she is continually challenging them to do better."

It's a balancing act, acknowledges Neethling, but staff members are responsive when they have a seat at the table. "This is not a top-down thing that has been mandated. There are obviously budget constraints that have to be followed, but the biggest success from this whole thing came from the fact that the front-line people who were actually doing the job were listened to and taken seriously," she says. "They felt they had some ownership, so that is a big part of what we are still trying to work on every day."

Things don't always go smoothly, to be sure, stresses Neethling. There may be a staffing issue on the floor, or a patient may not get moved along as quickly as he or she should. These issues come up on a daily basis and you have to keep working at them, she says. "However, when you establish ownership, it makes a huge difference. You don't feel like you have to keep pushing people. You can actually work with them and walk with them in the right direction, and encourage others to follow in the same way."

Empower nurses

The charge nurse plays a key role in any ED, but in this model, she or he is the ring master for the department, says Milne. "It is incumbent on the charge nurse to be working hand-in-glove with the physicians to be clear on what workups are being done, where they are at, and making sure that patients who are in the department are only there for as long as they need to be, and then they are disposed efficiently," he says. "The goal of the charge nurse is always to know where the next [free] room is going to be, and to keep the room ready effectively for the next patient who walks in the door."

If every room is full, the charge nurse needs to know which patient can be moved to a discharge holding area or out into the hall so a workup can be initiated on the next patient, explains Milne. "There is some learned skill in this process. It is not natively intuitive because most of the time nurses who are coming from other facilities tend to have the default feeling that if the patient has been triaged and is out in the waiting room, that's fine. They will deal with the patient when a bed opens up," says Milne. Conversely, in this no-wait model, the pressure is always on to make sure that a bed is always available to do an intake, he adds.

The model also takes advantage of protocols and order sets to enable nurses to get things done early on in the ED visit. "We've got a fairly standardized set of orders that we use for abdominal pain, chest pain, and with regard to plain film X-rays," explains Milne. "We give a lot of latitude to the nursing staff to be able to get orders placed as they need to before the physicians have completed their full assessment. That is a key to this."

This aspect of the model requires a change in thinking for many physicians as well as nurses who have worked in more traditional settings. "It's getting the nursing staff empowered to make decisions about what a patient needs, and to start thinking about using their training to move things forward, so there are a number of components to it," says Milne.

Get used to parallel processing

One of the challenges administrators at the Issaquah ED ran into when they began to implement the no-wait concept was the mentality among many of the ED nurses that it was a sign of weakness to have someone come in and help them with a patient, says Milne. "They were used to doing everything themselves, but they were using serial processing," explains Milne. As a result, it would take 20 to 30 minutes to complete the intake process on a patient.

Conversely, with the "swarming" intake process, there are typically three or four people carrying out several tasks simultaneously, so getting over this mental hurdle took some time, explains Milne. "Once the nurses were able to embrace the concept, the department started humming and moving a lot more efficiently," he says.

There has to be ownership and understanding and teamwork for the model to work well, explains Neethling. "There cannot be anyone, including the physicians, who is a solo flyer because then it doesn't work," she says. "Staff need to learn to respect and rely on other people, including people from other departments that service the ED."


  • John Milne, MD, MBA, Vice President, Medical Affairs, Swedish Medical Center, Issaquah, WA. Phone: 425-313-1000.
  • Anne Neethling, RN, Nurse Manager, Emergency Department, Swedish Medical Center, Issaquah, WA. Phone: 425-394-0610.