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ED overcrowding and boarding is a global phenomenon that negatively affects patients, hospital staff, and hospital-wide operations. Poor patient flow has been identified as a major contributing factor to ED overcrowding and boarding, which is directly linked to negative patient outcomes. This project implemented a multidisciplinary rounding team that addressed barriers to patient flow in real time. By reducing the inpatient length of stay bed capacity will improve, which in turn will help alleviate ED boarding and overcrowding.This before-and-after process improvement project took place on a 30-bed, inpatient medicine floor of a level-I trauma, tertiary, regional transfer center. Multidisciplinary rounding was used to improve care team communication and collaboration. Concepts from a Real-Time Demand Capacity model were used in this project to help develop a plan for capacity issues regarding bed supply and demand. Outcome variables included inpatient length of stay and ED boarding hours.Implementation of multidisciplinary rounding resulted in a statistically significant reduction of 0.83 days in the length of stay for patients on this floor. By increasing inpatient bed capacity, ED boarding hours for patients targeted to the 3000-medicine floor was reduced by an average of 8.83 hours per month, a reduction50% from baseline.Increasing inpatient bed capacity helps decrease ED access block, and contributes to reducing ED overcrowding. Implementing a daily multidisciplinary rounding structure on the inpatient floor helped hospital throughput by expediting discharges, which in turn created inpatient bed capacity.

Crowding in the emergency department is a problem worldwide that can affect patient safety and clinical outcomes. The aim of this project was to evaluate a multimodal quality improvement intervention with a new patient flow manager to reduce ED length of stay and ED bed occupancy.This single-site interrupted time-series analysis study was conducted in a tertiary hospital emergency department in South Korea. Interventions for a novel system load-balancing approach included a data-driven patient flow tracking informatics system, adding medical specialists, point-of-care creatinine testing (when required before diagnostic imaging) with dedicated imaging test slots for emergency patients, and introducing patient flow managers. Records of adult patients visiting the emergency department from January 2016 to March 2020 were included. Outcomes were ED length of stay and ED bed occupancy. Regression discontinuity analysis of an interrupted time series was used adjusting for seasonality and the number of patients per staff.A total of 46,494 patients in the preintervention period and 151,802 patients in the postintervention period were included. After the intervention, ED length of stay decreased by 4.07 hours, whereas the slope indicated a return to preintervention levels over time. Monthly average ED bed occupancy decreased by 34.6%, and the slope remained consistent over time.The multimodal quality improvement intervention that included a patient flow manager was an effective intervention to reduce the ED length of stay and the ED bed occupancy at the study site. The change for length of stay may not sustain over time without further intervention.

Problem Emergency departments throughout the nation are experiencing crowding related to increased patient volumes and decreased hospital inpatient bed capacity. As a result of lengthy wait times, patients are leaving without having medical treatment, and satisfaction is poor. The purpose of this quality improvement initiative was placing a provider in triage to complement the existing split-flow process aimed to decrease wait times to see a provider, length of stay (LOS), left without being seen (LWBS) rates, and improve patient satisfaction. Methods A multiprofessional team was established. Nurses, advanced practice providers, and physicians collaborated on a project to place a provider in triage to assist in seeing patients as soon as possible and begin care or treatment. Results The outcomes of the initiative were positive for ED LOS metrics and patient satisfaction. Door-to-provider time decreased from a high of 56 minutes to a low of 13 minutes. The percentage of patients LWBS decreased from a high of 12% to a low of 1.62%. Discussion The project showed that the evidence-based practice of a combined split-flow and provider-in-triage model resulted in improvements in throughput for patients who were treated and released from the emergency department.

Introduction Contemporary emergency departments experience crowded conditions with poor patient outcomes. If triage nurses could accurately predict admission, one theoretical intervention to reduce crowding is to place patients in the admission cue on arrival to the emergency department. The purpose of this study was to determine if triage nurses could accurately predict patient dispositions. Methods This prospective study was conducted in a tertiary academic hospital's emergency department using a data collection tool embedded in the ED electronic information system. Study variables included the predicted and actual disposition, as well as level of care, gender, age, and Emergency Severity Index level. Data were collected for 28 consecutive days from September 17 through October 9, 2013. Sensitivity and specificity, positive and negative predictive values, and accuracy of prediction, as well as the associations between patient characteristics and nurse prediction, were calculated. Results A total of 5,135 cases were included in the analysis. The triage nurses predicted admissions with a sensitivity of 71.5% and discharges with a specificity of 88.0%. Accuracy was significantly higher for younger patients and for patients at very low or very high severity levels. Discussion Although the ability to predict admissions at triage by nurses was not adequate to support a change in the bed procurement process, a specificity of 88.0% could have implications for rapid ED discharges or other low-acuity processes designed within the emergency department. Further studies in additional settings and on alternative interventions are needed.

Introduction ED crowding is a complex phenomenon that presents many challenges to patients, hospitals, and staff. Using Lewin’s change model, we implemented an ED improvement plan, including an innovative bed traffic control and improved flow system. We hypothesized that this plan would reduce door-to-provider time and emergency medical service–offloading time, decrease the length of stay and number of patients leaving without being seen by a physician, and increase overall patient satisfaction. Methods We examined the ED improvement plan’s impact on institutional throughput metrics over a 4-year period (2015-2019). Data on door-to-provider time, door-to-discharge time, patient volume, leaving without being seen by a physician, and patient satisfaction by Press Ganey were analyzed. Results Between 2015 and 2018, the median door-to-provider time decreased 56.9% and the median door-to-discharge time decreased 29.6%. Percentage of patients who left without being seen by a physician decreased 73.8%. In 2018, the patient satisfaction rank increased by 16 points (84.2% increase). Emergency medical services–offloading time decreased significantly, prompting a change of the 30-minute cutoff to 20 minutes. In 2018, 0.84% of patients had an offloading time of more than 20 minutes. Preliminary 2019 data show maintenance of this trend for all hospital metrics. Discussion Implementing a pod system, with flow and bed placement managed by bed traffic control, reduced door-to-provider time, door-to-discharge time, leaving without being seen by a physician, emergency medical service–offload time, and increased patient satisfaction. Our results may provide a model for other emergency departments to effectively manage the challenges of crowding.

Introduction Boarding, especially among psychiatric patients, has been characterized as a significant cause of ED crowding, but no quantitative analysis has described boarding nationally. This study determines the incidence, duration, and factors associated with ED boarding in the United States. Methods 2008 National Hospital Ambulatory Medical Care Survey ED data were stratified by visit type (psychiatric vs. non-psychiatric), boarding status, and patient and hospital characteristics. Boarding was defined as a visit with an ED length of stay >6 hours, and boarding time as ED length of stay minus 6 hours. Pearson's chi-square tests describe hospital and patient characteristics stratified by boarding status. Multilevel multivariable logistic and linear regressions determine associations with boarding and boarding time. Results While 11% of all ED patients boarded, 21.5% of all psychiatric ED patients boarded. Boarding was also more prolonged for psychiatric ED patients. Controlling for confounders, odds of boarding for psychiatric patients were 4.78 (2.63-8.66) times higher than non-psychiatric, and psychiatric patients boarded 2.78 (1.91-3.64) hours longer than non-psychiatric. Discussion US EDs experienced high proportions and durations of boarding with psychiatric patients disproportionately affected. Additional research concerning mental health care services and legislation may be required to address ED psychiatric patient boarding.

Problem Emergency department nurses are faced with an overwhelming number of patients each day. The average number of emergency department visits is increasing by 3.5% per year. Numerous studies have been conducted to improve the patient throughput process, which has impact on patient flow. A disruption of the process can cause a backlog of patients and create a hardship for both patients and staff. Methods The Plan-Do-Study-Act (PDSA) cycle was used as a specific improvement methodology for improving patient throughput and served as a component for the Model for Improvement approach. The article presents a quality improvement initiative created and implemented to improve patient flow by adding a flow nurse coordinator. The flow nurse coordinator was proposed to improve patient throughput by expediting and facilitating transport of the admitted patient to an inpatient bed. Results The average time from notification of bed assignment to patient arrival to an inpatient bed was 104 minutes, almost twice the proposed benchmark and more than the regional average. The results of the quality initiative changed patient arrival to inpatient bed from 104 minutes to 84 minutes, a decrease of 20%. Discussion The quality initiative team made several recommendations based on the research of a flow nurse coordinator. The recommendations included a weekly ED staffing committee meeting, consisting of frontline ED staff, nurse educators, ED leadership, and flow nurse coordinator. The support and active involvement of the executive leadership team would assist in sustaining changes to the new process.Unlabelled BoxContribution to Emergency Nursing Practice •The current state of scientific knowledge on emergency department overcrowding indicates a need to improve patient throughput. •The main finding of this research is to improve patient throughput, improve patient and staff satisfaction, and improve patient outcomes. •Key implications for emergency nursing practice from this research are to decrease the risk for medical errors, missed and delayed treatments.

Introduction Attempting to reduce ED crowding, the ED team at a rural academic medical center and specialty hospital implemented rapid medical evaluation (RME) with and without a provider in triage (PIT). The purpose of this performance improvement project was to explore how these interventions affected crowding metrics of door-to-disposition time, ED length of stay (LOS), and left without being seen (LWBS) rates for all patients. Methods Using a prospective 2-group design, the pre-RME population served as the historical control group, and postintervention groups included both RME with and without PIT. Group comparisons of crowding metrics included pre- and post-RME with and without PIT. Results There were no statistically significant differences in any of the crowding metrics for the emergency severity index (ESI) 3 groups pre- or post-RME. However, mean door-to-disposition times for the post-RME ESI 5 population were shorter compared with the pre-RME ESI 5 patients (2:59:23 vs. 2:00: 42; P = 0.037). Analysis of the post-RME population with and without PIT did not demonstrate significant differences across ESI 3 or 5 groups. Comparisons of post-RME data revealed a significant increase in ED LOS for all admitted patients regardless of their ESI (P = 0.023) and also door-to-disposition times for ESI level-4 patient groups, both with and without PIT (P = 0.022). Implications for Practice The findings support other studies demonstrating that RME can have positive impact on ED crowding metrics for some patients. Although PIT took longer for some patients, anecdotal findings revealed benefits related to direct discharges and admission occurring during the RME process.

Background The percentage of patients who leave the emergency department without being seen by a provider is a measure of efficiency and presents risk-management concerns. The number of patients actually "seen" by a provider is a measure of productivity. The opening of our new emergency department in December 2012, resulted in increases in both demand and the percentage of patients who left without being seen. Operational nursing leadership managed ED patient flow, but the structure was loosely organized on an ad hoc basis. Methods Operational nursing leadership roles were re-assigned to personnel with management aptitude and interest. The charge nurse coordinated care throughout all sections (pods) of the department while the pod lead nurse coordinated care in each pod. The flow coordinator nurse accepted transfers and emergency medical services arrivals. Nursing and physician staffing remained unchanged, and measures were calculated over a 3-year period (December 3, 2012, to December 2, 2015). The number of patients seen per day was analyzed using simple linear regression. The percentage of patients who left without being seen was analyzed using fractional logistic regression; P Results The weekly mean number of patients seen per day rose 13% from 265 to 299 patients. The weekly mean percentage of patients who left without being seen declined 45% from 8.2% to 4.5%. The regression lines for both measures were significant at P Conclusion Measures of efficiency and productivity can be improved significantly with a dedicated operational nursing leadership structure without adding nursing or physician staffing.Image 1Contribution to Emergency Nursing Practice •In the emergency department, the number of patients seen per day is a measure of productivity. •The percentage of patients who leave without being seen is a measure of efficiency. •Dedicated nursing management structure can improve productivity in the emergency department and the efficiency of flow.

Introduction High triage volumes can delay rapid identification of walk in ESI level 2 patients. This concern coupled with persistently increasing volumes prompted the Reading Hospital Emergency Department to move from single-tiered triage to duel-tiered rapid triage in 2008, then brought the addition of the RN Greeter in 2011. The purpose of this study was to assess how rapid triage then the RN Greeter impacted the ability to quickly identify the walk-in ESI 2 patient. Methods A retrospective analysis of mini-registration to triage time was conducted on ESI level 2 patients entering the ED by means other than ambulance. Data was collected from three separate time frames: The first representing single-tiered triage, the second duel-tiered rapid triage, and the third duel-tiered triage with the RN Greeter. Results Data demonstrated despite increasing volumes both rapid triage and the RN Greeter improved the prompt identification of ESI 2 patients. Discussion While moving from single to duel-tiered triage met little resistance from staff, the RN Greeter role was initially not as well received. However, as empirical data demonstrated the efficacy of the RN Greeter to quickly identify the potential ESI 2 patient, the role ultimately became an integral part of triage.

Our hospital was encountering problems with ED crowding. We sought to determine the impact of implementing a full-capacity protocol to respond to anticipated or actual crowding conditions. Our full-capacity protocol is based on collaboration among multiple hospital units.We completed a quality improvement initiative using a pre/post analysis of all ED patient encounters after implementing a full-capacity protocol with a corresponding period from the prior year. The principal outcomes measured were patient volume, admission rate, patient left without being seen (LWBS) rate, length of stay, and ambulance diversion hours.In the post-full-capacity protocol period, a 7.4% increase in emergency patient encounters (P.001) and an 11.9% increase in admissions (P.001) were noted compared with the corresponding period in 2013. Also noted in the study period were a 10.2% decrease in LWBS rate (P = .29), an increase in length of stay of 34 minutes (P.001), and a 92% decrease in ambulance diversion hours (111 fewer hours, P.001).The collaborative full-capacity protocol was effective in reducing LWBS and ambulance diversion, while accommodating a significant increase in ED volume and increased hospital admission rates at our institution.

Introduction: The Emergency Nurses Association and other groups have encouraged the adoption of patient flow improvement strategies to reduce ED crowding, but little is known about time and expenses associated with implementation. The purpose of this study was to estimate the time spent and expenses incurred as 6 Urgent Matters hospitals planned and implemented strategies to improve patient flow and reduce crowding. Methods: We conducted key informant interviews with members of the hospitals’ patient flow improvement teams at 2 points in time: immediately after strategy implementation and approximately 6 months later. A total of 129 interviews were conducted using a semistructured interview protocol. Interviews were recorded, transcribed, and coded for analysis. Results: Eight strategies were implemented. The time spent planning and implementing the strategies ranged from 40 to 1,017 hours per strategy. The strategies were largely led by nurses, and collectively, nurses spent more time planning and implementing strategies than others. The most time-consuming strategies were those that involved extensive staff training, large implementation teams, or complex process changes. Only 3 strategies involved sizable expenditures, ranging from $32,850 to $490,000. Construction and the addition of new personnel represented the most costly expenditures. Discussion: The time and expenses involved in the adoption of patient flow improvement strategies are highly variable. Nurses play an important role in leading and implementing these efforts. Hospital, ED, and nurse leaders should set realistic expectations for the time and expenses needed to support patient flow improvement.

Introduction ED crowding is a public health crisis, limiting quality and access to lifesaving care. The purpose of this study was to (1) evaluate the feasibility of radio-frequency identification tags to measure clinician-patient contact and (2) to test the relationship between ED occupancy and clinician-patient contact time. Methods In this 4-week observational study, radio-frequency identification tags were worn by emergency clinicians in a 21-bay urban teaching hospital emergency department. The time-motion data were merged with electronic medical repository patient information (N = 3,237) to adjust for occupancy, age, gender, and acuity. Qualitative themes were generated from focus group (N = 39) debriefings of the quantitative results. Results Data were collected on 56,342 total clinician events. Adjusting for patient age, increasing ED occupancy increased the number of times the attending physician entered and left the patient room (b = 0 .008, 95% confidence interval [CI] = [0.001-0.016], P = 0.03). There was no relationship for patient gender, triage acuity, shift at arrival, disposition to home, or discharge diagnosis category with either total minutes or number of encounters per patient visit. No time-motion and occupancy associations were observed for nurses, residents, or nurse practitioners/physician assistants. Debriefings indicated occupancy influenced the quality of care, despite maintaining the same quantity of contact time. Discussion The physical environment and clinician privacy concerns limit the feasibility of wearable tracking technology in the emergency setting. Attending physician care becomes more fragmented with increasing ED occupancy. Other clinicians report changes in the quality of care, whereas the quantity of time and encounters were unchanged with occupancy rates.Unlabelled BoxContribution to Emergency Nursing Practice •The current state of scientific knowledge on clinical-patient contact time indicates ED crowding may be detrimental to the quality, quantity, and consistency of care. •The main findings of this research include the following: As occupancy increases, we did not observe differences in time and motion for nurses and nurse practitioners/physician assistants, and we found that attending-physician care becomes more fragmented. There are several physical, architectural barriers to deploying radio-frequency identification tags in the emergency setting. Participating clinicians relayed several qualitative benefits and drawbacks to wearable tracking technology. •Key implications for emergency nursing practice indicate that additional revisions and considerations are needed to enhance wearable tracker feasibility for emergency clinicians.

Introduction Freestanding emergency departments are full-service emergency departments with no attached inpatient facility. ED congestion and patient dissatisfaction may occur as patients requiring admission are waiting for ambulance arrival and transfer. A partnership between a freestanding emergency department and a private ambulance company was developed in order to reduce ambulance response times and ultimately ED length of stay. The aim of this manuscript was to describe the Partnership in Care program and evaluate the program's effectiveness. Methods The study used a pre-post/post-test summative evaluation design. A retrospective chart review was done for all patients discharged from the freestanding emergency department by the partnered ambulance company during the pre-test period, April 2004 to June 2004, and the post-test period, April 2005 to June 2005. Data variables included time of triage, time ambulance requested, time ambulance arrived, and discharge time. Institutional Review Board approval was obtained. Results There were 507 patients transported at discharge by the ambulance company. There was a 5-minute increase for mean ED length of stay although not significant. Mean ambulance response time was significantly reduced by 8 minutes. Discussion The program did not achieve the primary goal of reducing ED length of stay, however the private EMS workers provided countless hours of patient care to the freestanding ED patients without charge to the freestanding emergency department for the EMS providers' time.

Emergency departments are affected by overcrowding, which may lead to diversion and cause delays in emergency services. In the past decade, overcrowding has become a significant national problem, with critically ill patients being diverted because of a lack of space and resources. Diversion of ED patients also is problematic from an administrative perspective, as it is a loss of potential revenue for the institution. The decision for diversion is made when it is deemed that the emergency department is at capacity or the hospital does not have sufficient bed capacity. A similar decision-making process is applied to critical care diversion and is contingent on the lack of available critical care beds. Also affected by ED overcrowding and diversion are EMTs, who transport the ill and injured. EMTs are challenged with finding alternative hospitals and dealing with prolonged transport times, which is a burden for the EMTs and potentially puts patients at risk. According to a study by Begley and colleagues, there could be a correlation between diversion and death rates among the most severe trauma patients transferred from lower-level hospitals. The state of New Jersey has a 2-tiered emergency response system consisting of Basic Life Support (BLS) and Advanced Life Support (ALS). BLS care is provided by either professional providers or volunteers and conducted under the direction of the local government. ALS operates under the auspices of the New Jersey Department of Health and Senior Services and is provided by a hospital-based Mobile Intensive Care Unit; while the volunteer BLS services generally are freestanding and nonregulated. All requests for EMS receive a BLS response, and patients with critical medical conditions additionally receive an ALS response; as a result, 2 vehicles are dispatched. Within our catchment area, BLS providers are EMTs or First Responders, and ALS providers are paramedics. Word Net Book defines diversion as sending on a course or direction different from the one that was planned or intended. In New Jersey, diversion cannot be mandated by a hospital; it is only an advisory status. Therefore, ambulances with critically ill patients have the discretion to utilize a diverted emergency department (see Table 1 for descriptions and definitions of diversion). Emergency service providers can be affected dramatically by hospital diversion. The decision of which emergency department to utilize often is not clear because of geographical distance between hospitals. Available resources and prolonged transport times factor heavily in the decision making. The authority to utilize an emergency department or hospital that is on diversion may be heavily scrutinized by a hospital staff that is already stretched to capacity. This situation creates a potential source of conflict between the EMTs and the ED staff. The purpose of this study was to identify the perception of hospital diversion by EMS providers and how these perceptions affect their management. This study specifically evaluates how diversion affects comfort level of care providers, reception of ED personnel, EMS, and patients, along with barriers to the continuum of care. This issue is important, because EMS providers are critical members of the emergency service team and have Gayle Walker-Cillo, New Jersey ENA, is ED Clinician, Morristown Memorial Hospital, Morristown, NJ.

Lisa Fryman, Bluegrass Chapter ENA, is Trauma Nurse Coordinator, University of Kentucky, Lexington. Linda Murray, Bluegrass Chapter ENA, is Staff Nurse and Preceptor, Emergency Department, University of Kentucky Medical Center, Lexington. For correspondence, write: Lisa Fryman, RN, University of Kentucky Medical Center, 800 Rose Street, N 207, University of Kentucky, Lexington, KY 40536-0293; E-mail: Lisa.Fryman@uky.edu. J Emerg Nurs 2007;33:208-13. Available online 16 February 2007. 0099-1767/$32.00 Copyright n 2007 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.11.014

Introduction The purpose of this study was to evaluate the efficacy of the newly developed fast track (FT) area in a University-affiliated emergency department. The goals of the FT unit included reducing patients' length of stay, improving patients' satisfaction, and decreasing ED overcrowding. Methods An exploratory descriptive design used to investigate length of stay in the emergency department, the rate of patients who left without being seen, unscheduled return visits to the emergency department within 72 hours of being seen, and patient satisfaction. Results During the evaluation period, 5995 patients were seen in the ED fast track area. The average time patients spent in the emergency department was 4.36 hours. The average time in room for the FT area was 1.97 hours. The left-without-being-seen rate for this time period for the main emergency department was 7%; the rate for the FT area was 4%. Additionally, 100% of respondents who completed a patient satisfaction survey in the FT area rated the care received by the nurse practitioner (NP) as good or excellent. Conclusions Although the average time in room and overall length of stay did not meet expectations, patients did move more quickly through the department after the addition of the FT unit. Patient satisfaction data suggested that the FT staffed by NPs is a welcome addition to the emergency department. The findings provide direction for the future study of NP utilization in the emergency department.

Problem For emergency departments experiencing crowding and a high percentage of patients leaving without being seen, a telephone triage service can provide other care options for low-acuity patients. Methods A nonexperimental pre- and postintervention comparative design was used to measure ED visit volumes from Medicaid and uninsured patients presenting with a low-acuity health care problem. Visit volumes for the 12 months before and 12 months after the initiation of telephone triage were compared. Results The overall low-acuity visit volume increased in the first 12 months of telephone triage availability. However, the proportion of low-acuity Medicaid and uninsured patients seeking ED care decreased. For the first 12 months of operation, telephone triage received 10,055 calls. Sixty percent of the calls (N = 6086) were from uninsured and Medicaid patients. More than 43% of the calls resulted in a self-care decision. Implications for Practice A telephone triage service may help decrease ED crowding by communicating other care options to patients with low-acuity health problems.

Problem Struggling to keep up with The Centers for Medicare and Medicaid Services out-patient throughput metrics, an adult emergency department serving Burlington and Camden Counties, New Jersey, sought to redefine its care delivery model by adopting the patient segmentation initiatives of the split-flow process of patient care. Methods A multidisciplinary team of ED clinicians collaboratively defined the patient segmentation criteria. A joint assessment team approach to patient care was instituted. A 3-pronged approach was adopted to prepare staff for the patient care changes in line with an existing framework specified by the Institute of Medicine. Simulation and queuing analyses were used to estimate the accompanying resource needs. Results Since implementing split flow, the emergency department has witnessed significant improvements in patient throughput and patient satisfaction, despite a sustained 10% increase in patient volumes after split-flow implementation. The median length of stay for discharged patients and the door–to–diagnostic evaluation time are now down to 112 minutes and 30 minutes, respectively, compared with pre–split-flow values of 192 minutes and 72 minutes, respectively. Implications for practice Working collaboratively with all stakeholders to define the right patient care delivery model, combined with an understanding of the right resource assignments to optimally support that care delivery model, an emergency department can institute cost-effective changes to realize and sustain significant patient throughput improvements.

Problem A 7.2% increase in patient volume from 130,700 to 140,800 in 2012 prompted St Joseph's Regional Medical Center Emergency Department to review existing triage processes to decrease turnaround time. "Pivot triage" is a new, efficient intake process that entails use of 4 rather than 8 determinants to identify acuity levels. The purpose of this performance improvement project was to create alternatives to traditional triage to decrease ED length of stay and door-to-physician time. Methods After education, the pivot process was implemented using 4 determinants established by a multidisciplinary team. The pivot process was slowly implemented for 6 hours over a 1-week period to work out processing issues. Arrival time, door-to-physician time, and departure time from the emergency department were elements used to calculate the patient's turnaround time. Length of ED stay was collected monthly beginning in the fourth quarter of 2011. Comparisons were made after Pivot implementation in the fourth quarter of 2012. Results Despite the increasing volume, the mean door-to-physician time decreased from 71 to 40 minutes, a 43.7% reduction. The overall turnaround time decreased from 220 to 181 minutes, representing approximately a 17.7% reduction. The percentage of patients who left without being seen decreased from 2.5% to 1.0%. The pivot process improved patient flow in the emergency department, reducing time spent by the patient in the department. Implications for Practice The pivot process is a viable alternative to traditional triage. Nurses are able to accurately pivot patients with a reduced amount of information.

Laura T. Gantt, ENA Eastern Tarheel Chapter, is Research Chair,State Council, North Carolina ENA, and Administrator, Division ofEmergency and Transport Services, Pitt County Memorial Hospital,Greenville, NC; formerly, Manager, Adult Emergency Department,WakeMed Emergency Services, Raleigh, NC.For reprints, write: Laura T. Gantt, RN, PhD, 2100 Stantonsburg Rd,Greenville, NC 27835; E-mail: ltgantt@pcmh.com.J Emerg Nurs 2004;30:237-42.0099-1767/$30.00Copyright n 2004 by the Emergency Nurses Association.doi:10.1016/j.jen.2004.02.016

Introduction At our urban academic medical center, efforts to alleviate ED overcrowding have included the implementation of a "fast track" area, increasing the ED size, using hallway beds, and ambulance diversion. In October 2012, we began the first steps of a process that created a system in which the admission process involves equal amounts of pushing and pulling to achieve the balance necessary to accomplish optimal outcomes. The foundation of the initiative was based on the use of a BSN-educated emergency nurse as a flow coordinator; a position specifically empowered to affect patient throughput in the emergency department. Methods A determination of quality improvement was obtained by the local institutional review board for a retrospective analysis of all ED patient encounters 1 year before and 1 year after the implementation of the ED flow coordinator position. All patient encounters were included for consideration and calculation; no encounters were excluded. Results The flow coordinator program decreased length of stay by 87.6 minutes (P=.001) and lowered LWBS rate by 1.5% (P=.002). Monthly hospital diversion decreased from 93 hours to 43.3 hours (P=.008). Discussion Investing in a flow coordinator program can generate improvements to patient flow and can yield significant financial returns for the hospital. A decrease in diversion by an average of 49.8 hours per month translates to an annual decrease of nearly $20 million in lost potential charges. A decrease in the LWBS rate by 1.5% (31% relative decrease) per month translates to an annual decrease in lost potential charges of more than $5 million. Our research shows that an ED flow coordinator, when supported by departmental and hospital leadership, can yield significant results in a large academic medical center and that the program is able to produce an effective return on investment.

urban county government to provide oversight to the city's primary emergency response fire-based advanced life support EMS. Members of the EMAB include the following voting members: physician representatives from each of the 6 local hospitals, a representative from the local chapter of the Emergency Nurses Association, 2 at-large representatives from the local medical society, the fire/EMS service medical director, the local public health commissioner (who also serves as the physician chair of the EMAB), and an elected member of the local city council representing the urban county government. Non-voting members include the chief of fire and EMS, the assistant chief for EMS, and the emergency medical services training coordinator. The EMAB established a diversion subcommittee in 2008 to address delays in care associated with ambulance diversion.