Health Matters Blog

Redesigning the Flow of the Emergency Department

By: Brian Richardson

Emergency medicine has been plagued for decades by two significant issues: first, the issue of Emergency Department overcrowding and second, extended periods of time waiting to be seen by the physician, nurse practitioner or physician’s assistant.

Brian Richardson

Brian Richardson

Since the late 1990s and early 2000s to the present day, emergency departments have seen a significant increase in utilization. Some of this increase can be explained by limited access to primary care physicians and some by changes in the healthcare system. Regardless of the cause the result has been crowded emergency departments. Crowding has not been limited to the larger metropolitan centers and has just as readily been felt in the rural acute care and critical access settings.

It has been business as usual for emergency departments for many years. Smaller antiquated spaces, processes and flow models have been the norm for treating patients; sort of a one size fits all mentality. This model worked pretty well in the 1970s, 1980s and even the early 1990s but the uptick in visits resulted in these processes falling apart and generated dissatisfaction and markedly increased wait times.

Brattleboro Memorial Hospital Emergency Department was not immune to these issues. A thirty year old emergency department lovingly patched together over the years with remodels and improvements was not up to the task of handling the increased volume with ease.

In 2013 the groundbreaking for the new emergency department ensued at BMH. So too began the activity of changing our process. Teams of people and departments dissected the path that a patient travels in the department; from the moment they enter the door until the time they go home, are admitted to the hospital or are transferred from the facility for a higher level of care. This team asked the tough questions of why, who and how and can we do this better? How can we provide a better experience for the patients and the staff in the emergency department?

Emergency department nurses, unit coordinators and registration staff took the work done by the larger team and developed a process by which to bring the patients into the treatment rooms faster so they could be seen by the providers more quickly. They reviewed staff work flow and re-tooled as needed to build in contingencies for when our volume pushes the limits of our capacity. The focus became: “Where does the care happen and how is the care delivered safely, efficiently and with the greatest amount of privacy?”

Now, when a patient arrives at the emergency department registration window during the day and evening hours they are asked very few questions: name, date of birth, chief complaint and social security number. At the same time a nurse is paged to triage the patient into the most appropriate acuity level. One of the most important parts of this step is receiving an identification band. This band is unique to the patient and is the foundation for many safety processes.

Generally, if space allows, the nurse will lead the patient to a room in the emergency department where the more formal triage process will occur. When possible, the nurse will utilize the model of “the right patient for the right room”. Issues requiring fewer resources or acute care will be assigned to one of the minor treatment rooms.

In many instances the emergency department provider arrives at the room during the triage process or shortly thereafter. The team of physician, nurse and patient devises the most appropriate plan of care and executes that plan safely and efficiently.

The emergency department has taken the notion of a rapid care area and applied it to the whole department. All levels of acuity get to see the provider sooner rather than later. The right rooms are selected for the right patients, with more minor acuity patients being seen in our minor (Rapid Care Rooms) with just the right amount of resources applied to their cases.

So how has BMH faired in this process so far? At an average of 25 minutes, our wait times to see the provider are well under the CDC’s 40 minute national average for rural emergency departments. Our Triage level wait times are at or under five minutes and for minor acuity patients wait time is a minute and a half.

BMH emergency department’s commitment to the patient is to provide the greatest patient experience possible. Improved access to providers using the rapid care process, the convenience of shorter wait times, direct communication of the emergency department medical record with the patient’s primary care provider, access to the myriad of onsite diagnostics and specialists and care coordination with BMH’s care management department are a few ways that the BMH emergency department makes sure that we are here for you.

Brian Richardson is the Director of Emergency Services at Brattleboro Memorial Hospital. Brian has been involved in EMS for nearly 25 years and has been a paramedic for the past 20 years. He can be reached at 802-257-0341.

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