Virginia Hospital Uses AHRQ Toolkit to Improve Emergency Care

Patient Safety
November 2009

Bon Secours St. Mary's Hospital, a 320-bed nonprofit hospital in Richmond, Virginia, implemented AHRQ's Door-to-Doc patient safety toolkit after attending an AHRQ-sponsored training session in September 2008. The session was offered as part of an AHRQ Knowledge Transfer project. As a result of this training, the hospital emergency department (ED) experienced a decrease in the amount of time patients must wait to see a physician, a decrease in the number of patients who leave without being seen, and an increase in patient satisfaction.

In September 2006, St. Mary's had advertised a "30-minute guarantee" that the hospital staff would see all ED patients within a half an hour. Following the ad campaign, the St. Mary's ED experienced a 20 percent increase in patient volume, as well as an increase in the time patients spend in the ED. In an effort to increase capacity and decrease the time patients spend in the ED, the hospital implemented Door-to-Doc in December 2008.

After implementing Door-to-Doc, St. Mary's was able to decrease by nearly 50 percent the time patients must wait to see an ED physician—from more than 30 minutes to just 16 minutes. In the Door-to-Doc model, patient flow is split into "less sick" and "sicker" patient subgroups. This determination is based on a brief analysis rather than a full triage. The system has the advantage of keeping the vast majority of patients—those who are less sick—moving during busy times, rather than waiting in the lobby or the ED.

According to Mike Smithers, RN, Administrative Director, Bon Secours St. Mary's Hospital Emergency Services, the toolkit has also had a significant impact on ED efficiency and patient satisfaction. "The Door-to-Doc toolkit has enabled the emergency department to absorb additional volume, decrease the time patients spend in the ED, and improve patient satisfaction."

A key advantage with the Door-to-Doc model is that ED beds are reserved for sicker patients who truly need them. Less sick patients, who tend to be ambulatory, are not assigned beds; instead, they move among treatment areas as they would in a clinic setting. These patients remain dressed and mobile as much as possible, and they wait for lab and other test results away from the flow of other patients.

After implementing Door-to-Doc, St. Mary's was able to accommodate an increase in patient volume without experiencing any increase in the rate of patients leaving without being treated. The ED's patient satisfaction scores increased from the 70th to the 90th percentile.

In the five months after implementing Door-to-Doc, Smithers attributes the improvements in several of the ED's quality and performance indicators to the Door-to-Doc toolkit, which provides users with a roadmap for using ED resources more efficiently.

"The capacity planning and staffing components of the toolkit helped determine the type and number of staff and space resources needed in order to achieve a particular length of stay. By using these tools, we now know how many doctors, nurses, and rooms we need in order to achieve and sustain a desired length of stay," Smithers explains.

Moreover, by helping better match resources to demand, the Door-to-Doc toolkit enabled St. Mary's to repurpose unneeded space in the ED and add eight additional beds to its pediatric intensive care unit.

These improvements in the ED's performance have not only enabled St. Mary's to exceed its 30-minute guarantee, but have also prepared the hospital for its next advertising strategy: the "Bon Secours St. Mary's No-Wait ED."

The Door-to-Doc toolkit, developed through AHRQ's Partnerships in Implementing Patient Safety program, was first pioneered as an ED patient flow innovation in Banner Health System's Mesa, Arizona, facility, which has since closed. The innovation was a change in process flow that Banner termed "Door-to-Doc."

Impact Case Study Identifier: 
AHRQ Product(s): Partnerships in Implementing Patient Safety (PIPS)
Topics(s): Access to Care, Emergency Preparedness
Geographic Location: Virginia
Implementer: Bon Secours St. Mary's Hospital
Date: 11/01/2009

Improving Patient Flow in the Emergency Department. Agency for Healthcare Research and Quality, Rockville, MD. February 2008.

Page last reviewed October 2014