A team of 40 nurses at St. Lucie Medical Center was challenged with addressing and improving patient throughput and emergency department overcrowding. More than 42,000 patients visit the 24-bed department each year.

Through the lean principles of process improvement, unit leaders and staff created a smoother patient flow - while treating an increasing number of patients and decreasing door-to-bed time.

"The most exciting part is the initiative was driven by ED staff engagement," said chief nursing officer Nancy Hilton, MN, RN. "Our nurses own this initiative and the resulting positive outcomes. We have maintained these improvements for 18 months with no more space and an increase in ED visits."

Group Effort

Eager to share the outstanding results of his team's hard work, Jim Kruger, BSN, RN, director of emergency services, entered St. Lucie's ED staff in ADVANCE's 2009 Best Nursing Team awards program.

"The team has worked well together blending several styles, personalities and cultures to become successful," Kruger said.

Kruger and his team looked at the upfront procedure, redesigning triage from a "room" to a process.

Before patients are assigned to ED nurses, a paramedic greeter in the lobby takes their vital signs and logs chief complaints.

Next, patients are either placed in open beds or sent to a sub-waiting area,  a treatment initiation room,  for medical screening, testing and treatment.

As rooms become available, patients are transferred from the sub-waiting area. In turn, patients cleared for discharge are moved from ED beds to the sub-waiting room.

Backlog No More

The winter months bring an influx of part-time residents and visitors to South Florida and other areas of the state, and many hospitals run at full census during that time.

Before St. Lucie Medical Center changed its ED flow process, a full house meant a huge backlog; admitted patients waited in ED exam rooms until a bed became available.

"In the pre-lean days, we were divided into a fast track, main ED and auxiliary ED sections. Now, any patient coming in - regardless of acuity - is placed in an open bed," Kruger said.

Currently, as part of a bed management process, floors must accept patients within 15 minutes of receiving report. When the hospital is full and ED overcrowded, all floors - excluding ICU - can hold two lower-acuity patients in unit hallways until inpatient beds are available. "Of course, that doesn't happen very often," Kruger said.

Patients awaiting test results or transportation  are moved to the sub-waiting area, creating open beds for incoming patients.

By the Numbers

Under the current system, average arrival-to-bed time has decreased from 58 minutes to 9 minutes, and physicians see patients in about 20 minutes instead of 66. In the past 12 months, average length of stay in the ED has hovered around 2.45 hours - down from 3.7 hours.

"Our biggest accomplishment is,  as throughput volume grows with less treatment space, we can still get patients back to beds so quickly. I'm proud of the team's motivation and ability to sustain the metrics over time," Kruger said.

The ED also has significantly decreased the number of patients who leave without being seen by a physician.

"We went from a high of 7.2 percent to less than 0.6 percent," Kruger noted, and patient satisfaction scores are nearly 3.5 on a 4-point scale.

Outside Honors

In addition to ADVANCE's Best Nursing Team designation, other organizations also have recognized St. Lucie Medical Center's noteworthy improvements. For a national meeting last November, the team had submitted an abstract and poster presentation about their accomplishments and competed against 375 EDs from around the country.

"Ultimately, our staff was recognized by their peers and voted to receive the Genesis Cup - which acknowledged the ED for improvements and sustainability," Kruger said. "The team's accomplishments could be replicated in virtually any other hospital."

Currently, the unit has no vacancies and the hospital has not used agency or traveling nurses in the past 4 years. Kruger reported a "great" retention rate with less than 2 percent turnover.

"They're very cohesive and have a high regard and respect for each other," Kruger said. "I'm continually amazed by the compassion they show toward one another and their patients."