Outstanding Redesign Work in the Emergency Department

In the early 20th century, as medical care was progressing, and therapies became available that actually improved patient outcomes (like antibiotics and sophisticated surgical procedures), the Emergency Room became the place to go for serious injuries or acute medical problems. Later in the century, as medical care became more complex, and there was more specialization in medicine, the Emergency Department (ED) became a sort of “catch all” for anything that couldn’t be handled anywhere else in the system. If the doctor’s office was closed or the doctor was already too busy, patients were sent to the ED for real needs that were not truly emergencies. In 1965, with the advent of Medicaid and payments below what private practicing doctors would accept to cover the costs of running their practices, ED’s became the place where poor people went for care, not because they wanted to be there for non-emergencies, but because many doctor’s offices would not accept Medicaid. And finally, the aging of the population is another reason  Emergency Departments here, and around the country,  continue to be in high demand.

For the last few decades, ED’s have been under siege. The professionals working there are incredibly dedicated and well-trained. They work extremely  hard, but the system is not designed for efficient flow. 

The GBMC ED is operating under the same stressful situation as other ED’s. We, however,  have an advantage over most ED’s --  outstanding leadership. Dr. Jeff Sternlicht, Medical Director, and Mark Fisher, RN, Nurse Manager, have fully embraced our vision and have become quite proficient at redesign. With the help of our performance improvement advisors, they have redesigned much of the care of ED patients who don’t need to be admitted to the hospital.

There are three areas to focus on to improve patient flow in the ED:

1. Input: You can work to make sure that only patients with emergencies come to the ED. (This is the work of primary care, specialty physician offices, and other community providers.)

2. Throughput: You can work to reduce waste in the processes from check-in to discharge home. (Clearly the work of the ED team.)

3. Output: You can move patients to an inpatient bed as quickly as possible once you know they need to be admitted. (This is the work of the inpatient teams led by our hospitalists or inpatient specialists.)

Jeff and Mark have been happy to work with our patient-centered medical homes on reducing non-emergent visits and to work with our Department of Medicine in particular, to move admitted patients to the floor faster.  They have not wasted any time  getting in action to redesign the work of assessing and treating those who they think can be sent home – the throughput work. 

So, what have they done so far? 

Redesign of Triage:  They added a medical provider in triage to connect the patient to a provider sooner. This is allowing the Emergency Department to start care on entry, during busier times of the day. 

Implementing a Protocol Bay: This allows labs and IVs to be started right after triage. This gets blood sent to the lab sooner and test results back quicker for patients even before they get to a treatment space.

Implementing a Rapid Assessment Zone: This allows patients with lower acuity needs to have their care started in the waiting room even before they get to a formal treatment bed.

Yesterday on our Lean Management System rounds, Katie Koestler, RN4, presented the ED’s results so far. I am so proud of Jeff, Mark, and their team. They are doing phenomenal redesign work and moving us faster toward our vision. They are clearly improving the care experience and reducing wasted time in the ED. Please thank the members of the ED team when you see them!