The Rhode Island Hospital emergency department in Providence was built 10 years ago and is one of the busiest teaching hospital emergency departments in the country. Treating more than 100,000 adult patients a year and admitting almost 30 percent of them, the department has such a high acuity that part of its 100-bed ED is dedicated to critical care patients. The Andrew F. Anderson Emergency Center (AEC) is the main teaching site for The Warren Alpert Medical School of Brown University and its many residency programs. It is one of the top-ranked emergency medicine residency programs, and its clinical metrics for sepsis, ST-segment elevation myocardial infarction, pneumonia, and stroke are among the best reported in the country. It is a center for research on medical teams, injury prevention and control, and resuscitation science.
All this aside, the leadership at Rhode Island Hospital—hospital president Peg Van Bree, DrPH, and Brian Zink, MD, chairman of the University Emergency Medicine Foundation—decided that they were not satisfied with the operational metrics for the department. Like most high-volume tertiary teaching hospitals, they struggled with operational metrics like door-to-physician time, length of stay (LOS), and left without being seen (LWBS) rates. After intensely studying their operational data, they learned that lower-acuity patients suffered most in terms of wait times and delays.
The leadership team—which includes David C. Portelli, MD, James E. Monti, MD, and Alexis Lawrence, MD, nursing leaders Susan Patterson, RN, and Lindsay McKeever, RN, and advanced practice provider (APP) leader Lisa Murphy, PA—decided that they needed real transformative change. The leadership team decided to stop all committee work on operations and to use the task force model for process improvement recommended by Brent James, MD, of Intermountain Healthcare. They participated in a retreat where they reengineered patient flow and workflow in their department. Armed with a charter and a tight project timeline, the team developed an ambitious change package, named AEC 2.0, involving four big innovations that would go live at once. Using the major care/minor care model that has proven successful in Great Britain, they designated areas in their department as prime care for major medical cases and focused care for patients with limited problems and an expectation of discharge (see Figure 1).