15-30’ commitment key to reduced wait times

Added personnel, equipment speed patient flow

"Dramatically reduced emergency department waiting times" was one of the major reasons cited for the awarding of this year’s Malcolm Baldrige National Quality Award to Robert Wood Johnson University Hospital (RWJ Hamilton) in Hamilton, NJ.

This recognition makes RWJ Hamilton only the fourth health care facility to ever win the prestigious award.

At the heart of the turnaround was the hospital’s "15-30" concept — a commitment to patients that they would see a triage nurse within 15 minutes of entering the ED, and a physician within 30 minutes, or the ED would absorb the treatment fee.

In tracking its performance, the ED at RWJ Hamilton finds it is meeting its target more than 98% of the time.

The "15-30" concept was pioneered by the RWJ facility in New Brunswick, NJ, recalls Debbie Cardello, the COO at RWJ Hamilton, but her facility had to implement its own targeted initiatives to make it successful there.

"We began considering it in 1998," she notes. "We took a similar approach [to RWJ New Brunswick], but we had lots to do to accomplish it since we were paying so much attention to throughput."

An interdisciplinary team was assembled, which included the medical director of the ED, Al Rodriguez, MD; the administrative director; the lab; X-ray; admissions; finance; and administration.

"We knew we would need them all to support the effort to improve throughput," Cardello explains.

The first step was to increase the number of telemetry beds, so patients could get through more quickly.

"We initially added 20, and ultimately 32, which has doubled our total," she notes.

Staffing also was increased. "We added a 24-hour triage nurse, and [we] added another physician for peak hours and a separate one for fast track, which we call Prompt Care," Cardello reports. "We also added a greeter, and one bedside registrar per shift."

In addition, she notes, a pneumatic tube system was installed to expedite receipt of lab results.

Create a rapid-admit team and unit

While a number of changes were made at the outset, the overall improvement in patient flow also depends on constant reevaluation and new initiatives, explains Debbie Baehser, vice president of patient care services.

"Over the years, we have developed more initiatives to support the program," she notes. "Because our volume has increased so dramatically, the numbers change all the time."

One of the initiatives added later was the development of a rapid-admit team, which is a nursing staff to support the inpatient unit. "This helps us treat patients more quickly in the ED and get them to [inpatient] beds," Baehser explains.

Members of the rapid-admit team go to the nursing unit where the patient is admitted and complete all paperwork.

The team began with one additional RN per shift, and now a second RN has been added during the peak hours of 11 a.m. and 11 p.m. "It has been very beneficial," she says.

Also, about a year ago, an admissions unit was started, which is a six-bed unit that helps to pull patients out of the ED, where quick treatment can be initiated. "These patients are there for four hours or so, and then sent to an inpatient unit," Baehser explains.

While initially one triage nurse was added, there are now two additional nurses during peak hours. "We also trialed having a physician in triage this summer, and it greatly helped decrease wait times," she says.

Then, in December, the hospital authorized the institution of computerized physician order entry, which will enable physicians to enter their own orders in a more timely manner.

A multidisciplinary team continually monitors ED processes, as well as those in other areas of the hospital that affect the ED. The team includes the nursing director, the ED medical director, Cardello, Baehser, plus ancillary and inpatient units.

"We monitor inpatient units as well as the ED, because they dramatically impact [flow in] the ED," explains Baehser, adding that the hospital uses a color-coded chart (green, yellow, red) that indicates the status of the ED, and specific interventions other departments can institute to help return the ED to "green" status if it is in yellow or red.

In evaluating the impact of all these initiatives, RWJ Hamilton decided against simply calculating "before" and "after" average wait times, Cardello says.

"We started to monitor our progress and found that a more comprehensive look would be helpful," she explains. "So, we’ve tracked the number of refunds we give — which have been very low, under 1% or 2% — rather than measuring timeliness per se," Cardello continues.

In addition, the department has found that its left-without-being-seen numbers are lower than 2%, "which is really a best practice across the nation," she adds. The hospital also keeps track of patient satisfaction.

These days, Cardello notes, "very few people are registering complaints."

Sources

For information on improved ED wait times, contact:

  • Debbie Baehser, Vice President, Patient Care Services, Robert Wood Johnson University Hospital Hamilton, One Hamilton Health Place, Hamilton, NJ 08690. Phone: (609) 586-7900.
  • Debbie Cardello, Chief Operating Officer, Robert Wood Johnson University Hospital Hamilton, One Hamilton Health Place, Hamilton, NJ 08690. Phone: (609) 586-7900.