Proving That ‘‘Less Is More’’: The Emergency

Department at Florida’s North Broward Medical Center

Reduces Minor Care Turnaround Time

C L I N I C A L N O T E B O O K

Authors: Donna Small, RN, BSN, MBA, Phil Ragusa, RN,

MBA, Boris Kaltienko, MS, MIS, MCSE, and Jane Neubauer,Deerfield Beach, Fla

Section Editor: Anne Marie E. Lewis, RN, MA, CEN

Donna Small is Chief Nursing Officer at North Broward MedicalCenter, Deerfield Beach, Fla. Phil Ragusa is Regional Manager ofEmergency Services at North Broward Medical Center, DeerfieldBeach, Fla. Boris Kaltienko is PACS Administrator, and formerly theClinical Systems Training Specialist, at North Broward MedicalCenter, Deerfield Beach, Fla. Jane Neubauer is Community RelationsSpecialist, North Broward Medical Center, Deerfield Beach, Fla.

For correspondence, write: Jane Neubauer, North Broward MedicalCenter, 201 E. Sample Rd., Deerfield Beach, FL 33064; E-mail:J1neubauer@nbhd.org.

J Emerg Nurs 2006;32:258-60.

0099-1767/$32.00

Copyright n 2006 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2006.03.012

258

Earn up to 8 CE Hours. See page 291.

outh Florida’s North Broward Medical Center, an

Sadult level II trauma center with more than 60,000 pa-

tient visits per year, is part of the North Broward Hos-

pital District, a tax-supported health care system that serves

as a safety net for the uninsured in Broward County. For

5 years the emergency department volume increased by 5%

annually, with patient visits in the Minor Care area (Station

A) increasing by 8% each year. However, processes to ac-

commodate that growth had not kept pace. Patients on

average were spending 130 to150 minutes in the Minor Care

area. Frustrated by the amount of time they spent waiting,

many persons left without receiving treatment.

Today at the Medical Center, ‘‘less is more.’’ This

motto is not merely an old adage, it is a proven method

for success. The hospital’s emergency department has suc-

cessfully implemented an innovative Fast Track process

that has dramatically reduced ‘‘turnaround time’’ (TAT)

for Minor Care patients. In fact, patient wait time has

decreased from 153 minutes to 87 minutes for this group

of patients, less than the national benchmark of 90 min-

utes, achieving best-in-class performance for the hospital.

The hospital’s strategic plan was to raise average pa-

tient satisfaction scores from 63% to 91% for the emer-

gency department overall. For the Minor Care area, scores

surpassed this goal and reached 99%—an all-time high for

any area of the emergency department. This TAT success

demonstrates that less time in the emergency department

means more efficiency overall.

Isolation is good

North Broward Medical Center strives to be the health

care system of choice for the community it serves. To

JOURNAL OF EMERGENCY NURSING 32:3 June 2006

C L I N I C A L N O T E B O O K / S m a l l , R a g u s a , K a l t i e n k o , a n d N e u b a u e r

target this goal, a team of representatives from all affected

areas of the hospital—Radiology, Clinical Education, Dis-

trict Information Services, Patient Access, Laboratory, Nurs-

ing, and Guest Relations (Figure 1)—developed a specific

plan. The team determined that a positive ED experience

would encourage patients to choose the hospital for other

medical needs as well. Focusing on the emergency depart-

ment was a key factor to improving TAT, because 75% of

patients who visit the emergency department do not require

hospital admission.

FIGURE 1

Staff from North Broward Medical Center who participated in

the TAT process improvement effort. Back row from left to

right: Patricia Fulmer, RN, Antoinette Besbris, ER tech, ToddWeeks, ARNP, Donna Small, CNO, Judy Stuparitz, RN, Boris

Kalitenko, Picture Archiving and Communication System (PACS)

administrator, Phil Ragusa, RN, regional manager of Emergency

Services at NBMC. Front row from left to right: Anna Rivera,

ER tech, Vanessa Aberle, Patient Access specialist, Melinda Bess,

Patient Access Specialist, and Brenda Loston, Environmental

Services tech.

June

The hospital’s emergency departmenthas successfully implemented aninnovative Fast Track process that hasdramatically reduced ‘‘turnaroundtime’’ (TAT) for Minor Care patients.In fact, patient wait time has decreasedfrom 153 minutes to 87 minutes forthis group of patients, less than thenational benchmark of 90 minutes,achieving best-in-class performance forthe hospital.

Two root causes were identified for the prolonged

TAT. Staffing hours were not optimized to meet patient

demands, and patient flow and information systems were

not interfaced adequately with practitioners in the Minor

Care area. The need to address each of these root causes

was verified by statistics showing that 77% of patients

who spent more than 90 minutes in the Minor Care area

spent an excessive amount of time in the waiting room.

This situation was deemed unacceptable by the hospital’s

administration and its Quality Council. The patient flow

inadequacies were compounded by the emergency depart-

ment’s information tracking system, FirstNet, which did

not communicate effectively with the staff to alert them

when patients were nearing the 60-minute or 90-minute

mark. This situation could result in patients falling beyond

the emergency department’s goal of a 90-minute TAT for

Minor Care patients.

2006 32:3

Putting process into action

The team utilized rapid cycle improvement methodology—

Plan, Do, Study, Act—for process improvement. Changes

included the following:. Adjusting staffing. A nurse practitioner now ar-

rives in the emergency department at 9 AM—an

hour prior to the scheduled start time for Fast

Track—to begin assessing patients before the Fast

Track opens and to do prep work that otherwise

would have to be done at 10 AM (Figure 2). The ED

physician schedule was not changed, and that

person’s shift begins at 10 AM daily.. Adjusting patient flow. The nurse and ED technician

for the Minor Care area start their shift at 9:45 AM

so they can set up the station and move patients to

that area for treatment that begins immediately at

10 AM. (The largest volume of patients arrives at the

emergency department between 10 AM and 10 PM).

This step reduced wait time by 20 minutes, a 31.74%

improvement, because the patients were taken out of

the lineup with the main ED patients.

JOURNAL OF EMERGENCY NURSING 259

FIGURE 2

Antoinette Besbris, ER tech, is ready to assist as Todd Weeks,

ARNP, examines a Minor Care patient in the emergency

department.

FIGURE 3

FirstNet’s tracking system alerts staff to waiting times for

patients who are being treated for Minor Care issues. A yellow

signal indicates a 60-minute wait time, while a red signal indicates

that the patient has been in the department for 90 minutes.

C L I N I C A L N O T E B O O K / S m a l l , R a g u s a , K a l t i e n k o , a n d N e u b a u e r

. Improving patient flow. Treatment rooms are turned

over more quickly because patients are not waiting

in rooms for discharge instructions. They wait in

a designated ‘‘chairs’’ discharge area, resulting in an

8.1% increase in patients seen in the Minor Care area

during hours of operation—from 37 to 40 patients.. Enhancing the FirstNet information tracking system

to include a timer to alert staff. A yellow warning indi-

cates a 60-minute wait time, and a red warning signals

that a patient has been waiting 90 minutes (Figure 3).. Training staff to effectively utilize the system. The

staff now knows to ‘‘hustle’’ when they see the sys-

tem’s yellow or red warning signals. If a red indicator

comes on the screen, staff is alerted that patients

soon will be beyond the 90-minute goal, so they

have to prioritize accordingly. In just 1 week, TAT

for Station A decreased from 128 to 115 minutes.

Less is more

The emergency department also benefits financially by

treating more Minor Care patients without increasing ex-

penses. Productivity has gone from 86% to 104%. A de-

crease in patients leaving without treatment is another

plus. The next step will be improvements in TAT for higher

acuity patients.

‘‘We looked at our existing process and at how we

could effectively reallocate our resources,’’ said Kevin

260 J

Fusco, chief operating officer of North Broward Medical

Center. ‘‘Between 35 to 55 patients daily receive Minor

Care treatment, and following the changes, the volume

of patients has increased. The majority of them have given

the Minor Care area a 10 out of 10 score on the emergency

department’s own patient satisfaction survey.’’

OUR

The emergency department also benefitsfinancially by treating more Minor Carepatients without increasing expenses.Productivity has gone from 86% to104%. A decrease in patients leavingwithout treatment is another plus.

Pauline Grant, chief executive officer of North Broward

Medical Center, comments, ‘‘For the past 10 months, we

have successfully maintained our goal of under 90 minutes

for getting patients seen in the Minor Care area. These days,

patients are searching for quick and efficient high-quality

care, and that is what they say they are receiving here.’’

Submit descriptions of procedures in emergency care and/or quick-reference charts suitable for placing in a reference file or notebook to:

Anne Marie E. Lewis, RN, MA, CEN, Section EditorSubmit Clinical Notebook manuscripts online at http://ees.elsevier.com/jen/

NAL OF EMERGENCY NURSING 32:3 June 2006