Hasbro Children’s Hospital (HCH) is a busy pediatric hospital in Providence, Rhode Island, and a teaching hospital for the Brown University School of Medicine. Part of the Lifespan Health System, it is staffed by physicians from the University Emergency Medicine Foundation (UEMF), which is dedicated to running operationally sound and efficient emergency departments. The emergency department treats 52,000 patients a year in its 36 beds. The leadership team was looking to re-engineer patient flow and workflow to become more efficient. It had been on a journey to improve wait times and performance metrics.

In March 2014, the emergency department reported wait times to see a clinician of 72.4 minutes, something anxious parents regularly complained about. The emergency department began a number of improvement initiatives including a “pull to full” project, which traded a lengthy traditional triage process for a quick-look triage and bedside triage and registration process. The results were very promising and wait times were cut in half. However, the ED leaders—Frank Overly, MD, medical director; and Lynn Pittsinger, RN, nursing director—wanted to do more. The department was struggling to efficiently manage low acuity patients and a growing behavioral health (BH) burden. Together, the leadership formed a highly functional improvement team that included physicians—Laura Chapman, MD, Linda Brown, MD, and Elizabeth Jacobs, MD—nurses—Samantha Leary, Maureen O’Neill-Britt, Stacy Schindle—and a data analyst, Dennis Ferrante. This team developed an ambitious group of changes and prepared for implementation. The project was dubbed “Expedite to Excellence” or E², and this appeared on posters and emails sent to staff.

A few things to note about pediatric emergency medicine patients:

• Children have a lower rate of being admitted (10.4 percent according to the most recent Emergency Department Benchmarking Alliance survey), equating to a possible shorter length of stay (LOS).
• Pediatric patients have a greater need for procedural sedation. This has implications for space and staff and for what conditions might be treated in a fast track setting.
• Even blood draws or IV placement can be a two- or three-person task, especially in younger patients who may need staff to hold them still for these procedures. This has staffing implications (ie, more certified nursing assistant or tech support).
• Pediatric volumes are lower on mid-week days and in the summer months and higher on Mondays and Sundays, which has more staffing and patient flow implications.
• Pediatric BH complaints are on the rise and these patients have longer LOS. This affects bed utilization and has a de facto “boarding” effect.

The Hasbro leadership set out to right or remedy its flow problems. It decided that instead of tinkering with small changes, they would implement a “change package” with a number of initiatives that would go live all at once. The change package included the following improvements:

1. Design and Standardize the Flow Model: Conceptually, the leadership supported a flow model that streamed patients to geographic areas according to their acuity and anticipated resource utilization. The model is depicted in Figure 1, and part of the implementation included flow standardization and keeping the model clinician independent.
   

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