In early 2004, Children's Hospital Boston's Emergency Department (ED) leaders recognized that the ED wasn't functioning as efficiently as it could. So they hired external consultants to perform a research-based
analysis that took into account data on length of stay, obstacles in the admitting process and other elements of the ED experience.
Many of the changes that followed were implemented between 2005 and this past summer, including key initiatives such as Quick Registration and expanding the system for immediate bedding of ED patients
arriving at triage throughout the day and evening. ED nurses also organized a group to meet with inpatient unit nurses to address delays in patient transfers. "That step in particular made a huge impact on patient care," says Fran Damian, MS, RN, director of Nursing/
Patient Services in the ED. In addition to these
communications and procedural changes, ED staff physically transformed a utility room into a lab, allowing them to quickly perform rapid influenza, RSV, strep and pregnancy tests, thereby eliminating time-consuming waits for results from the main lab.
Just as these improvements were being implemented, Children's ED, like emergency departments across the country, began to see an unprecedented surge in
volume: In the fiscal year 2005, it treated about 4,000 more patients than usual. The surge took the Children's ED administration by surprise, since the department's volume had been steady for a decade. But the surge wasn't just in patient volume: In 2005, the Children's ED also saw a sharp rise in acuity. "It would have been utterly catastrophic had we not put all those
improvements into place and then had the current volume," says Anne Stack, MD, director of clinical operations in Emergency Medicine. "We've just kept up with the hurricane."
To make sure every patient has a nurse, and all patients receive timely care, Children's ED has nearly doubled staff on certain shifts. The ED has been in such demand, it opened an off-site location last January, turning Children's pre-op clinic into an extension of the ED on evenings and weekends. "We thought that was going to be a temporary fix, but now it's standard operating procedure," says Dr. Stack. "We would not have been able to sustain the gains without it."
The volume and acuity crisis didn't slow down the improvement plan, however. In November, the ED opened nine new, state-of-the-art exam rooms and a charting area with the goal of facilitating collaboration and consultation among ED staff and specialty services. Among the changes planned for the future are a new entryway and triage area, a reconfigured registration space and a central core support section that will include a new pharmacy and supply area.
