Emergency department (ED) overcrowding has ripple effects throughout a hospital, often leading to tensions between ED and inpatient staff.

At Sun Health Del E. Webb Hospital, ED clinicians led an effort to redesign their care processes to accommodate rapid growth in patient volume. Building on their confidence and teamwork, ED nurses, led by Noreen Vanca, R.N., B.S.N., administrative director of Emergency Services, launched the "Build a Bridge" program, in which they reach out to their counterparts in other departments to explain the new system and address any problems that arise. The approach is a simple, low-cost way to encourage communication and collaboration among hospital departments.

An Overwhelmed ED
Sun Health Del E. Webb Hospital is a nonprofit, 330-bed facility located in Sun City West, Ariz. Originally a retirement community, this part of the Sun Belt has attracted younger residents in recent years: the aptly named town of Surprise, Arizona, has ballooned to 125,000 citizens, from just 35,000 five years ago. As a consequence, the number of patients visiting Sun Health has grown by 20% each year since 2001, with many arriving via the emergency department.

This higher patient volume overwhelmed the ED. Rates of patients who left without being seen (LWBS) climbed to a high of 14% in April 2005. Waiting times were typically six to eight hours, stretching to 10 hours during peak times. Both patients and providers were frustrated by the ED gridlock.

A New Model of Care
In October 2005, Sun Health administration hired Insight Strategies, a consulting firm, to help the ED reengineer their care delivery processes. The effort was led by a multidisciplinary team of ED physicians, nurses, and technicians, who developed the following guiding principles:

• Patients come to the ED because they want to see a physician;
• Performing the traditional triage process creates delays in diagnosis and treatment;
• Not every patient needs to own a bed; and
• The greatest risk to ED patients is the waiting room.

Computer simulations revealed that the patient flow patterns at Sun Health--with queues building at the point of triage--would consistently result in overload. The team decided to eliminate the triage process, an approach gaining currency in U.S. hospitals (see Innovation). Instead, a "quick look" personnel technician checks patients' vital signs and then sends them to a treatment area, where an immediate assessment is performed by a physician and nurse. Patients are no longer assigned to permanent beds; different functions, from physical exams to data collection and procedures, are performed in different parts of the facility, thus most efficiently using the available resources.

The redesigned system has enabled the ED to overcome gridlock and better serve patients. In six months, ED length of stay decreased from five hours to a little over three hours. In June 2006, the LWBS rate fell to .001% (10 patients out of 3,200 visits). Patient satisfaction scores on the Press Ganey survey--which had been 9% before the redesign--climbed to 85% of patients saying they were satisfied with their care.

In letters of thanks to Sun Health, patients describe their ED experience as "efficient" and "expeditious," but also note the "sensitivity," "care," and "thoroughness" of the ED staff. The hospital created a DVD of patients reading excerpts from their letters, accompanied by video footage from the ED. According to Vanca, when the DVD was shown during a department meeting, there were a few tears among the normally tough-as-nails staff.

Building Bridges Between Departments
During the redesign, ED staff worked as a team to come up with their own solutions to overcrowding. ED nurses, in particular, gained confidence in their ability to address operational issues. Once they had proven they could effectively meet patients' expectations and partner with ED physicians, technicians, and EMS, they focused on strengthening relationships with their colleagues in other departments.

"Having our staff lead the ED redesign was great--they felt empowered to make any change they needed, and they wanted to share this feeling," says Vanca.

Often, inpatient hospital staff perceives the ED as creating work for "upper floors" by calling for more and more tests, and bringing up patient after patient. This was particularly the case at Sun Health, where 75% of all admissions originated in the ED. Sun Health nurses conceived the Build a Bridge program as a way to reach out to other departments and develop joint solutions to recurring problems.

Each month, a pair of ED nurses visits another hospital unit. Typically, they bring candy to break the ice and attract attention from passersby. The nurses describe the new system in the ED and solicit feedback on how it is affecting other parts of the hospital. ED nurses are encouraged to respond to any comments, even outright complaints, with thanks and a promise to look into the matter. During staff meetings, they discuss feedback from a particular department, looking for patterns and trends.

One sticking point for floor nurses was that the ED often sent them patients during shift changes, when they were writing up reports. Why couldn't there be some "no admission" time? But for the ED system to work, patients had to be admitted as soon as possible, to clear a bed for new arrivals. Initially, the nurses reached a compromise: each day, a half hour was blocked off, during which no patients were admitted from the ED. Eventually, as floor nurses became used to the system and saw patient satisfaction increase with speedier admissions, they dropped even this half hour of blocked-off time and now have ongoing admissions.

ED nurses incorporated other suggestions into their work routines, including adding more detailed information, such as the DNR status, to the report sheet that accompanies each admitted patient.

Empowering Staff
Getting a handle on patient flow has raised staff morale. When there were long waits, "ED staff had gotten used to starting every conversation with 'I'm sorry,'" says Vanca. "That gets pretty demoralizing." Before the redesign, there had been a high turnover rate (32%) among ED nurses as well as a high vacancy rate (36%). Today, the ED is fully staffed and turnover is low. The "Build a Bridge" program of staff-driven, collaborative problem-solving provides a strong foundation for the ED's new way of working--enabling effective partnerships among the ED and other hospital departments.

"Our staff was pretty proud," says Vanca. "They had proven they could find a better way of working in the ED; they used this momentum to build relationships with their hospital colleagues."

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Del E. Webb Memorial Hospital
Sun Health Del E. Webb Hospital has undergone extensive expansion since its founding in 1988 in order to meet the healthcare needs of communities in the northwest area of metropolitan Phoenix.

Due to an increase in the number of families moving into the communities served by Sun Health, Del E. Webb Hospital has broadened the scope of medical and clinical service. The hospital excels in providing acute medical and surgical services as well as intensive care, emergency and urgent care, inpatient /outpatient surgery, cardiac catheterization, neurology, orthopedics, oncology, urology, pulmonary, obstetrics and gynecology, extended care, outpatient diagnostic services, acute and outpatient rehabilitation and adult behavioral services.

Staffed beds: 330
Hospital type: Public, not-for-profit

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Noreen Vanca, R.N., B.S.N.
Administrative Director
Emergency Services
Del E. Webb Memorial Hospital