By Dorothy Brooks
As pandemic-related surges eased, clinical leaders in the ED at Cooperman Barnabas Medical Center in Livingston, NJ, realized they needed to improve their patient flow process.
“What motivated us was [the opportunity] to provide better patient care,” explains Eric Handler, DO, FACEP, chairman of emergency medicine at Cooperman Barnabas. “We realized that wait times were way longer than we would want for ourselves, our families, and friends, and we knew that we could do better.”
Maria Aponte, MPA, BSN, RN, administrative director of emergency services at Cooperman Barnabas, says leaders always wanted to keep the waiting room empty. However, as the days wore on, it was not uncommon for 20 to 30 patients to be waiting for care during peak hours.
Although patients still saw a provider, on average, in about one hour, the leave-without-being-seen (LWBS) rate was a concern (around 5%). “That’s a dangerous situation, and we took it as a safety concern,” Aponte says.
To address the problem, leaders performed time studies to pinpoint where the bottlenecks occurred. While the front end of the process worked well, beds in the back of the ED were not turning over fast enough to keep patient flow moving. This meant the ED would need cooperation from all the services that conduct business with the department to address their throughput problems.
Fortunately, with the support and engagement from the hospital’s C-suite, ED leaders established regular engagement with other departments, as well as an accountability mechanism so flow hold-ups could be addressed at the source, and appropriate resources deployed. “Initially, it was almost like a call for help. Then, we started to establish a committee where everyone started to look at their dashboards and their metrics to see how they were helping us to provide a service that we needed, whether it be radiology services or the services of the lab,” Aponte repots. “They understood that they were selling us a service, and we were able to highlight where their shortcomings were.”
For example, if it takes too long for a patient to undergo a CT scan, the radiology department will have to prepare an improvement plan, and then work collaboratively with the ED and other members of the throughput committee to correct the problem. “The C-suite has done an excellent job of being present for these meetings just to highlight, and back us up, on just how important this work is,” Aponte says. “The secret sauce is just everybody doing this together.” Before the new flow process debuted, Aponte made sure the ED was appropriately staffed with permanent employees so that it would be core staff learning the new process, as opposed to temporary employees or travel nurses. “I hired over 100 employees altogether last year in an effort to be able to execute what we have been able to do,” Aponte explains.
With all these pieces in place, ED leaders mapped out a new flow process. Patients would be brought back to a bed immediately after they were registered and assessed, essentially negating the need for a waiting room. The program went live on Jan. 4.
“On that day there were 30 people in the waiting room, a similar picture to what we had the day before, when seven patients walked out,” Aponte recalls.
However, at that point, Aponte and Handler took over the flow process. They proceeded to show staff how they wanted the new process to work. “Within an hour, we were able to clear the waiting room from 30 patients to zero just by being more efficient with the next empty bed and not waiting for it to be someone else’s job,” Aponte explains. “Dr. Handler was making sure there were beds available, and we were all just jumping in to make sure we [kept things moving].”
That was the first time the ED team saw the waiting room cleared. Aponte says staff have kept it that way just by continuously escalating any concerns that can bottleneck flow, and by working together to solve problems. Today, the LWBS rate is practically zero, and average wait times to see a provider hover around seven minutes.
Further, the process implemented in the ED at Cooperman Barnabas is now a model for the other 11 hospitals in the RWJBarnabas Health system. “We have been asked to pretty much take this [process] on the road at times or have people visit us to see how we do it,” Handler shares. “Each ED is a little bit different, but there are some best practices that can and have been learned.”
For other EDs struggling with long wait times, boarding, or other capacity challenges, Handler’s advice is to involve higher-ups early. Executive leadership must ensure engagement from all the departments that interact with the ED.
Another way to quickly lower the LWBS rate is to employ a provider in triage model, although Handler says this is more of a short-term solution, in part, because it is a “great dissatisfier” to providers. “We were asked to get the LWBS rate down, and that was the only way to do it [quickly] ... but it is more of a Band-Aid on the problem,” Handler says. “Once you show the facility that you can get the process started, and that the ED has the ability to take care of the patients, then you need help from outside the department.”
Aponte reiterates it is time to move on from the version of disaster medicine EDs became accustomed to during the pandemic, with all the social distancing and isolation. “Patients need to be touched ... and people need to feel safe,” she says. “Go back to the art of emergency medicine where the patient comes first.”
Further, Aponte suggests that when patients present to the ED, they should not feel like they are bouncing from one department to the next. Rather, patients should feel like their care is provided by a single, patient-centered, community-focused unit. “That is what we have been able to do here with all of us working together, and patients are starting to see it,” Aponte adds.
To prevent people from leaving an ED without seeing a provider, researchers identified bottlenecks, secured support from leadership, and engaged with all units that conduct business with the department to address throughput problems. Coordination and accountability helped solve flow issues at the source.
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