Manager: Not all EDs ready to convert to no-wait status

Eliminating waiting rooms takes years, cooperation

The new ED at Adventist GlenOaks Hospital in Glendale Heights, IL, is a bit untraditional: It has no waiting room.

"When a patient comes in the door, they are met by a greeter," explains Rebecca Girling, RN, nurse manager. "They call the nurses, we immediately go out there, put them on a wheelchair or stretcher, and take them straight to their room and start triage." As soon as the vital signs have been taken and bedside registration has created a chart, they are seen by physicians, usually within 30 minutes of the time they first entered the ED.

The old ED was one-third of the size of the new department with a waiting room. When patients came in the door, they would be seen by a triage nurse and then sent to the waiting room.

The staff and patients of the new department, which opened in June 2007, "love it," according to Girling. However, ED managers should not even consider such a move without years of preparation, warns Joseph E.F. Shanahan, Esq., MD, the physician director.

The new department was "the culmination of a long journey," says Shanahan, who notes that before the decision was made to go to no wait, the department already had reduced its wait times to 15 minutes. "A number of years ago, we decided we wanted everyone seen within 30 minutes of arrival," he recalls. "We literally had a campaign, and if a patient was not seen within 30 minutes, they were given free theater tickets." When the staff saw they could do this, they set a new goal of 15 minutes and achieved it. "We then realized we could see patients immediately if we had enough space," says Shanahan.

One of the keys was process changes; bedside triage and registration were implemented long before going to no-wait status. In addition, says Shanahan, "We had to sit down with radiology and lab services and insist our patients get preferential service."

All of these details have to be worked out before you even consider going to a no-wait process, Shanahan emphasizes. "You can't go from a typical ED where they wait two to three hours and do this," he says.

Even when the department had reduced its wait times to 15 minutes, Shanahan did not immediately jump to no-wait.

"My CEO had read an online blurb about a hospital in Indiana [Ball Memorial in Muncie] that had built a brand-new ED without a waiting room and asked me to consider it," he recalls. "I went down there to look but determined that if it was 'smoke and mirrors,' I wouldn't be interested."

So three years ago, Shanahan spent eight hours talking to doctors, nurses, patients, and technicians, "and was totally amazed it was not smoke and mirrors; they did not have a waiting room, and people were getting immediate service." Shanahan thought that because his facility was smaller (17,000 annual visits vs. about 40,000 at Ball), "we could take this same concept and do it better."

Even then, however, the department was not ready to commit. "I took our nurse manager, our marketing director, our VP, and nurses on a second trip so they could see it; they had to buy into it as well," Shanahan explains. "We spent four to six hours talking with our counterparts." Girling adds, "We really focused a lot on how that patient flow worked — from when they walked in the door to when they got to bed."

Finally, says Shanahan, he went to visit other EDs to consider different design options. "I must have toured 20 different new EDs around the U.S.," he says. "Most of them had up to 30% of their square footage in waiting rooms, so with this [no-wait] concept you could make your exam rooms larger, allowing patients and relatives to be inside the treatment area." Shanahan says he and the CEO found that concept appealing.

Not a huge step

As often happens with new initiatives, the nurses were skeptical of the proposed setup, says Girling. However, she adds, that reluctance also was mitigated by the progress that had been made to date. "We had that 15-minute time frame to begin with, so it was not a huge step; we were already doing bedside registration," she observes. "We did a little team building and had complete buy-in from the staff, which was critical."

Members of the staff came to see it as a challenge, she adds. For any new staff, it simply became part of their expectations.

In addition to eliminating wait time, the new department is more comfortable and welcoming to patients. There are 19 treatment rooms, compared to 10 in the old department, thanks to the elimination of the large waiting room. Based on his ED tours, Shanahan recommended a "racetrack" concept, which put all exam rooms on the periphery of the department. "That allowed us to include windows," says Shanahan, adding that with 11-foot ceilings they can be place high enough to eliminate the cost of window treatments while preserving privacy.

The patients "all love it," he says. "They feel like when they come in, service starts immediately." Girling adds, "They tell us they love having their families brought back with them."

Sources

For more information on creating a no-wait ED, contact:

  • Rebecca Girling, RN, Nurse Manager, Joseph E.F. Shanahan, Esq., MD, Physician Director, Emergency Department, Adventist GlenOaks Hospital, Glendale Heights, IL. Phone: (630) 545-8000.