St. Michael’s Tight Squeeze: Maximizing An Outgrown ED

The Emergency Department at St. Michael’s Hospital in downtown Toronto sees 72,000 patients per year – in a space built for 45,000.

“We have some pretty severe space restrictions, and we are always working to get wait times down,” said Dr. David MacKinnon, deputy chief of operations for the ED. “At the same time, our ED patient volumes are growing alarmingly fast, at about five to eight per cent per year. We needed a new model that would go a long way to maximize our space and help us see patients as quickly as possible.”

“Rapid Assessment Zones” or “RAZ” are in use in several hospitals on a small scale, but St. Michael’s recognized the model’s space-saving potential and implemented it for 60 per cent of its patients. Six months later, the result is a shorter wait for patients, thanks to a much more efficient use of what is a hot commodity in St. Michael’s tight quarters: exam rooms.

St. Michael’s is a Level 1 trauma centre equipped to receive the most severely injured patients. However these patients make up a relatively small portion of the total ED patient population. Almost two-thirds of the hospital’s ED patients – about 120 a day – are considered “minor.” That means that they may need tests or medication but are still reasonably comfortable sitting up and walking around.

Traditionally, “minor” patients would wait in an ED exam room for their initial assessment with a physician or nurse practitioner and remain there until all tests were complete and results analyzed.

With RAZ, these patients are hived off to a small, dedicated waiting area right outside a bank of exam rooms. Patients enter exam rooms only to interact with a physician or nurse practitioner, after which they leave the room and move on to another, nearby area to wait for test results. The quick turnover frees up the exam rooms for the next patients.

Each stage in the RAZ patient’s journey – from triage to the first waiting area, exam room, results area and then the exit – is located next to the previous one, with just a short walk between.

If the wait time to see a physician reaches more than two hours, the RAZ model also enables nurse practitioners to step in to assess the next patient waiting in line. In the past, nurse practitioners would see only patients triaged to them, based on the patients’ specific complaints.

“Having nurse practitioners and physicians working side by side has been a great change,” said Dr. MacKinnon. “Our patients are happier because they’re moving faster. And it’s a more collaborative environment for our staff.”

Patients deliver their own charts from triage to the RAZ coordinator, reducing the steps in the staff’s process. The St. Michael’s model is unique in that the RAZ coordinators do not have a clinical background. They focus on flagging excessive wait times, addressing administrative or logistical roadblocks and coordinating the frequent exam room changes.

The resulting reductions in wait times extend beyond RAZ patients; when the RAZ stream moves faster, “intermediate” patients on the cusp of “minor” can be re-triaged to RAZ, reducing bottlenecks for the sicker patients.

The St. Michael’s ED opened in 1892, consisting of a one-room emergency, a simple outpatient clinic and 26 beds. After several different incarnations, the ED moved to its current location in the hospital in 1983 and has changed little since.

Plans are underway to renovate St. Michael’s ED by 2018 and almost double its size.

“We thought the RAZ model would be a good short-term solution to keep us functioning until the new ED is built,” said Dr. MacKinnon. “But it’s worked so well that it’s now our new normal. It may sound like a lot of transitions for patients, but that’s part of the benefit – it’s healthier for ‘ambulatory’ patients to be up and walking around. We’ll continue with RAZ even when we have more space.”

Along with several more exam rooms, the new ED will feature quiet and comfortable waiting areas for family and friends, dedicated care space for mental health patients and additional, confidential workspace for ED staff. All design decisions are being made with the patient experience in mind, based on the best available evidence.