HOW TO CREATE A NEW EMERGENCYDEPARTMENT IN 21 DAYS OR LESS

Authors: Gina Castillo, MS, BSN, RN, CEN, Janet Shepard, MHA, RN, and Paul McHale, MD, Chandler, AZSection Editor: Susan McDaniel Hohenhaus, MA, RN, FAEN

Members of our 35-bed emergency departmentredesigned its care process to drastically reduceturn-around time and the number of patientswho left without being seen, with the limitation of usingcurrently available staff and space. The waiting room emp-tied. Our patient satisfaction grew, along with our staffsatisfaction. What did we do? Read on.

As Martha Beck1 has said, Any transition seriousenough to alter your definition of self will require not justsmall adjustments in your way of living and thinking, but afull-on metamorphosis. As health care professionals weknow that, in order to make a change, it is necessary torecognize that change is needed and then choose to makethat change.2

To make process changes in our emergency depart-ment, we needed not only the willingness of the ED staffbut also that of the ED physician group and the facilityadministration. As a group we needed to look at ouractions, our environment, and our assumptions with fresheyes. The enormity of the task and the recognition of theneed led our facility to seek the assistance of an outsidegroup (the facilitators).3

Representatives from each department of the facility,as well as a redesign team composed of ED physiciansand ED registered nurses and technicians, met for intensiveworkshops with the facilitators. Initial meetings focused onestablishing ground rules and defining customer expecta-tions and team goals. A primary rule of the ED redesign

group was that we could change what occurs in the emer-gency department but not in the rest of the facility. Thegroup also took in a high-level view of hospital-wide pro-cesses and the actual flow of patients through the emer-gency department. These processes were then subjectedto computer simulations by the facilitators, applying therapid redesign methodology.

Quality and service indicator factors necessary to suc-cess and factors that both drove and restricted the currentprocess were discussed. The team then met to redesign theprocess, keeping these factors in mind but also seeking toremove unnecessary programmed waits and redundanciesin action and documentation. The team also brainstormedabout ways to accelerate time to treatment and reducelength of service. These suggested changes also were sub-jected to computer simulation by the facilitators. The briskredesign process resulted in a short lead time for creatingforms, rearranging treatment areas, ordering equipment,and educating staff. (Seven stretcher bays were convertedto 2-recliner bays, allowing nurses to treat patients withintravenous fluids and narcotic pain medications. Visitorsare limited to one per patient in this confined space.)

One of the primary difficulties of the redesign was tochange the flow from being facility and departmentoriented to patient oriented. As caregivers, we seek tobe patient oriented. However, as a facility functioningwithin predefined processes, we often were forced tosqueeze our patient care moments into an inefficient pro-cess. Furthermore, the publics learned expectations of theED process required that, as part of the redesign process,we re-educate the patients, visitors, and even ancillarydepartments to remove assumptions about how, when,and where care is provided.

Our process included 3 principal changes:

1. Postscreening intake is performed simultaneously by botha nurse and physician, usually within 10 minutes of pre-sentation to the emergency department.

2. Diagnostics and medical management begin directly fol-lowing intake.

3. Not every ED patient requires a bed. By beginning physi-cian evaluation and treatment early in the visit and movingthe most acute patients to high acuity areas, the minor carepatients to an area utilizing the physician assistant, and

Gina Castillo is Charge Nurse, Emergency Services, Chandler Regional Med-ical Center, Chandler, AZ.

Janet Shepard is Director, Emergency Services, Chandler Regional MedicalCenter, Chandler, AZ.

Paul McHale is Immediate Past Medical Director, Emergency Services,Chandler Regional Medical Center, Chandler, AZ.

For correspondence, write: Gina Castillo, MS, BSN, RN, CEN, EmergencyServices, Chandler Regional Medical Center, 475 S Dobson Rd, Chandler,AZ 85224; E-mail: GinaC@chw.edu.

J Emerg Nurs 2011;37:165-6.

Available online 18 October 2010.

0099-1767/$36.00

Copyright 2011 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.

doi: 10.1016/j.jen.2010.09.016

C L I N I C A L N U R S E S F O R U M

March 2011 VOLUME 37 ISSUE 2 WWW.JENONLINE.ORG 165

moderate need patients to recliner areas,5 the waiting roomvolume became insignificant. Consequently, the numberof patients leaving without being seen dropped dramati-cally. Prior to redesign, an average of around 3% of ourpatients left without being seen, but this number peakedat 6.36% at the end of our busy season. Following rede-sign, our numbers were 1.32% the first month and downto 0.06% by the fourth month.

While our journey to a new emergency departmentmay seem fantastical to some, it most assuredly did happenas described. Not all facilities will have what existed as ouroriginal environment of care, but with a systemwide dedi-cation to improvement of patient care and reduction in lia-bility, this environment can be created at any facilitywilling to minimize ED crowding. First, a strong bondmust be forged between the physicians and staff in theemergency department. Second, the ED physicians andadministration must share similar goals, such as reducedlength of service, reduced turn-around time, and increasedpatient satisfaction. Finally, the administration must fullysupport the redesign process and be willing to considerengaging outside consultants such as our facilitators.

Of course, we had obstacles to overcome. Educationof the entire medical and nursing staff was absolutelyrequired. Asking the staff to make a leap of faith basedon the work of their peers was at times quite stressful.Zero tolerance was given to variation in practice by phy-sicians or staff for the first 30 days. Pesky issues arose,such as finding recliners that worked for both the patientand the nurse, revising forms, and telling the patientsrepeatedly that yes, indeed, that was a physician to whomthey just spoke. In fact, 89% of our patients are now seen

by the intake physician within 20 minutes of arrival to theemergency department.

At the establishment of the process, our desire as a unitand a facility was to reduce turn-around time and increasethe satisfaction of the patients and staff, reduce liability forED patients who leave without being seen, and use the lim-ited space available for use as a result of inpatient boarding.Our goals indeed have translated into successful outcomes.Our turn-around time in July 2007 was 231.6 minutescompared with 179 minutes in July 2008. We peaked at256.6 minutes in March 2008 but dropped to 202.8 min-utes in April 2008 and 176 minutes in May 2008.

Although any solution is site specific, the redesignshould incorporate pre-existing strengths and minimizethe pre-existing weaknesses of the site.

Other departments, seeing the success of our ED rede-sign, can bemotivated by the prospect of a redesign solved bythe very people who work day to day in their department.

REFERENCES1. Beck M. Growing wings. O Magazine. January 15, 2004. http://www.

oprah.com/spirit/Strategies-to-Deal-With-Every-Phase-of-Major-Life-Changes/5. Accessed April 21, 2008.

2. Peele S. Six principles of change. Psychol Today. May 1, 2004. http://www.psychologytoday.com/magazine/archive/2004/05. Accessed April21, 2008.

3. Adler S, Beyer R. Insight Strategies LLC. http:// www.insightstrategiesllc.com. Accessed April 22, 2008.

Submissions to this column are encouraged and may be sent toSusan McDaniel Hohenhaus, MA, RN, FAENSHohenhaus@ena.org

CLINICAL NURSES FORUM/Castillo et al

166 JOURNAL OF EMERGENCY NURSING VOLUME 37 ISSUE 2 March 2011

How to Create a New Emergency Department in 21 Days or LessReferences