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Rapid Recovery:
How Milton Hospital's Emergency Room Improved Efficiency and Increased Patient Satisfaction

In June 2008, construction of Milton Hospital's new Emergency Department was nearing completion: 16 state-of-the-art treatment rooms, including two critical care bays and five "fast track" rooms, a comfortable, spacious and secure waiting room, dedicated radiological services.

But as the hospital prepared to spotlight its new facility, it had fallen into the same trap as many other emergency rooms – rising wait and treatment times were becoming an alarming blemish on our untarnished amenities.

Milton Hospital's Emergency Department Task Force
In response to this mounting concern, a diverse group assembled to solve a spectrum of challenges. The Emergency Department Task Force represents many areas of the hospital: nurses, physicians and physician assistants, administrators, leaders from patient registration, the laboratory and care management. The group meets regularly to identify and address issues that impact emergency patient service.

"Many departments play an active role in emergency care. Lab tests carried out in a timely manner, efficient patient transport practices, patient floors that are ready to admit patients. These are all elements of an emergency program that is functioning at its best. It is Milton Hospital's commitment to our patients that we carefully monitor all of these influences."
Paul Paganelli, MD
Chief of Emergency Medicine
Milton Hospital

The Solution:
By re-examining patient flow, implementing new guidelines, adjusting staffing and redefining nursing roles, the Task Force helps bring significant improvements to the emergency patient experience at Milton Hospital.

Today, as our average door-to-door treatment time draws closer to the 180-minute national benchmark, patient satisfaction has dramatically increased and accolades for our delivery of care have become the norm.
Allow us to share with you some major changes that have transformed our emergency department into a destination for efficient and compassionate urgent care.

"Statistical improvements have been made thanks to the commitment of all staff. Many have made the matter of emergency wait times their own and welcomed the opportunity to continually find ways to improve."
Lynn Cronin, RN
Emergency Department Nursing Director
Milton Hospital

The 5-Tier Triage System
A visit to the emergency is not always a first-come, first-served experience. A key factor in your emergency visit is the triage process. The triage nurse is one of the most skilled and experienced nurses on the team. This nurse makes the very important first assessment of your emergency condition. This triage distinguishes potentially life-threatening cases from the less critical so that our medical staff can correctly prioritize treatments.

During the department's re-evaluation, Milton Hospital hosted renowned Nurse Educator Nicki Gilboy, RN, co-author of theThe Emergency Severity Index Implementation Handbook. Gilboy trained our emergency staff in the ground breaking five-tier triage process.

Five-tier triage categorizes patients in one of five levels of acuity:

FAST TRACK
Level 5: The least acute patients, requiring little treatment
Level 4: Patients likely requiring a quick consultation or a minor treatment, such as a lab test or prescription of medication
Level 3: More acute patients who may require multiple tests and more treatment

URGENT
Level 2: High risk patients who may exhibit signs of stroke, heart attack or other conditions that could become fatal

EMERGENT
Level 1: The most acute patients in immediate danger, exhibiting life-threatening conditions

Expanded PA Coverage for "Fast Track" Care:
Patients with less critical conditions (Level 3, 4 or 5) are normally assigned to our "fast track." Milton Hospital has five treatment rooms reserved for these patients, staffed by a physician assistant trained to treat these types of cases, and overseen by a physician. With double physician assistant coverage during peak hours, our dedicated "fast track" system is designed to continually move less critical patients through their treatment, even when more urgent patients arrive.
Sometimes "fast track" can be a misleading phrase. It is important to remember thatmost emergency patients fall into the "fast track" category. This simple fact can increase wait times, even for patients with minor conditions. Whenever possible, Milton Hospital moves patients into a treatment room as soon as space becomes available, so that emergency care can begin.

Recent patient surveys show our Patients' Perception of Care ranking has dramatically increased over the past several months, at times placing us among the top ten percent of Emergency Rooms nationwide.

30-Minute Admission Goal
Milton Hospital uses a bold 30-minute admission goal when admitting a patient. The clock begins when an emergency physician makes the decision to admit a patient to the inpatient unit. Immediately, staff step into action to coordinate a transfer out of the emergency department and into an inpatient bed. The 30-minute goal sets an aggressive standard for transferring patients and requires coordination between patient registration, nursing supervisors, housekeeping and emergency staff.

Whenever possible, Milton Hospital advances a patient's care by offering bedside triage. When a bed is available inside the emergency department, patients are moved out of the waiting room and into a treatment room. Once in a bed, patients are assessed and registered. This simple system helps get treatment started sooner.

"Bedside triage helps keep the waiting rooms clear and gives patients peace of mind that their care is underway."
Joe Bellabona, RN,
Emergency Department Nurse Manager
Milton Hospital

The Resource Nurse: The Emergency Department's Traffic Controller
Emergency room nurses fill many roles, particularly when the number of patients rises. Often during peak times, it becomes more challenging to monitor every patient's progress through treatment. A resource nurse fills this responsibility.
Resource nurses are trained to create a smooth flow within the emergency department by managing daily nursing assignments, changing assignments as needed and checking for suitability of nursing skill levels.

Bringing Major Hospital Emergency Care to Your Community
In January, Milton Hospital launched a partnership with Harvard Medical Faculty Physicians (HMFP) at Beth Israel Deaconess Medical Center to operate the Emergency Department – a move that immediately resulted in shorter wait times during peak hours.

The group brings with it the experience of treating in a major city emergency facility and offers new perspectives on improving care and service.

New Facilities Meet New Standards of Care
With a major construction and renovation project now complete, our emergency department combines state-of-the-art facilities with compassionate and well-managed care. Our 16 treatment rooms are modern and private, our waiting room is clean, bright, spacious and secure and our emergency staff is well trained, efficient and caring.

You probably aren't ready for a medical emergency, but Milton Hospital's emergency department is ready for you.

Milton Hospital's Expanded Emergency Services:

• Modern triage area emphasizing patient privacy and comfort
• 16 private treatment rooms, including five designated "fast track" rooms for less critical patients and two critical care bays for highly critical patients
• An overall area twice the size of our original facility
• A state-of-the art triage center
• A separate-entrance decontamination room
• Dedicated radiological services
• 24-hour security