May 22, 2025 Emergency Measures

Hospitals have taken metric-driven steps to make Ed care faster, safer and better.

Christopher Freer, DO, knows the impression that many people have of hospital emergency departments (EDs). “They’re notoriously overcrowded with long waits, and the expectation is that you’ll come in and it will be a mess,” he says.

As Senior Vice President, Emergency and Hospitalist Medicine at RWJBarnabas Health (RWJBH), Dr. Freer also understands that this expectation can sometimes come uncomfortably close to reality. That’s why RWJBH has rethought, reorganized and reinvigorated ED care systemwide.

The initiative has resulted in dramatic improvements. Now some patients are commenting on how efficient and effective emergency care has become. “When that happens, you know you’re doing something right,” Dr. Freer says. “What we’ve done is take concepts that should be simple and kept them simple.”

Yet making a complex process simple takes thought, planning, teamwork, coordination and communication. That’s evident at an ED such as the one at Cooperman Barnabas Medical Center (CBMC), one of the health system’s largest. “There might be 70 people coordinating care with patients, with each patient having a different complaint,” Dr. Freer says.

“It requires an interdisciplinary process that involves many colleagues, all of whom need to buy in,” says Jennifer O’Neill, DNP, APN, NEA-BC, Chief Operating Officer at CBMC.

Strategies to raise the standard of ED care that began being implemented at CBMC in 2022 have since spread to all 12 hospitals in the RWJBH system. “We’re not done,” Dr. Freer says, “but it’s working.”

Patient-First Priorities

At the core of the initiative is the concept of putting patients first. In a busy setting with a lot of steps happening all at once (including arrival, intake, triage, exam, testing, diagnosis, admission and transport), it’s tempting to organize processes in ways that prioritize staff needs. For example, patients might start by providing detailed registration information.

Dr. Freer knows what that can look like. “A line forms for registration,” he says. “Then there’s a line for the triage nurse. Everything flows into the waiting room. You can see the bottlenecks.”

Chokepoints factor into a key metric that’s used as a national benchmark of ED performance. It’s called LWOBS—left without being seen. “That means you walk in, go through lines, there’s no bed available, so you sit, time goes by—and you decide you don’t want to wait, so you leave,” Dr. Freer says.

To members of RWJBH emergency teams, that’s unacceptable. “If a patient leaves without being seen, we’ve failed the communities we serve,” Dr. Freer says. “Our updated process changes the order of things.”

The transformation begins the moment a patient walks through ED doors. “We have an experienced nurse stationed near the front door who says, ‘Good evening, what brings you here today?’” Dr. Freer says. “Minimal information is taken at that moment— for example, your name—but you’re in the system, you’re given a wristband and care can begin immediately. We get patients to a room where they see a doctor, nurse, physician assistant or nurse practitioner.”

Triage to determine care priorities and any necessary testing comes next. “While you’re waiting for lab or scan results, that’s when registration team members come back around to complete your information,” Dr. Freer says.

Another key concept is what’s known as pull to full, meaning patients are pulled into rooms as quickly as possible until beds are full. If beds aren’t available, patients can go to a telehealth portal where a provider sees them remotely and starts care by, for example, ordering tests.

Overall, emergency care accelerates. Patients are discharged or admitted to the hospital, and ED beds open again so more patients can receive services.

Marks of Improvement

The new process leverages information in the Epic electronic medical records system—now implemented throughout RWJBH—to optimize patient flow. That’s especially important for the 15 to 20 percent of ED patients who are admitted to the hospital and sent to inpatient beds.

In a process called e-handoff that’s coordinated by a crucial hospital logistics team, the system automatically generates electronic notifications when ED providers request an inpatient admission. Notifications tell inpatient providers that a patient is coming, alert ED providers when a bed is available and guide patient transport from emergency to inpatient care. “This all needs to happen expeditiously and safely,” Dr. Freer says. “It’s a critical piece of the patient journey through the hospital.”

Metrics such as LWOBS and the time it takes to move patients to inpatient beds are carefully tracked and communicated to providers across all disciplines and departments. “An email goes out every day,” Dr. Freer says. “Every hospital knows whether or not goals or targets are met.”

Results have been impressive. “Our LWOBS percentages are significantly below national averages, and some of our hospitals are close to zero,” Dr. Freer says. “ED patients move to inpatient beds in 30 to 40 minutes, which is much faster than in the past.”

A more efficient ED reflects a more efficient hospital overall, says Dr. Freer, who credits O’Neill with supporting improvements through her teams. “We couldn’t do this without all the inpatient pieces working for our patients,” he says. “It’s a true team effort.”

The improvements have changed attitudes toward EDs. “Our patient experience scores are as high as they’ve ever been pretty uniformly across all our sites,” Dr. Freer says. This triggers an additional, significant benefit. “When all this works and patients are happier, staff morale goes way up,” he says. “Our staff retention rates are higher than they’ve been in years.”

The combination of efficient care, better quality and the best patient experience is readily summed up, Dr. Freer says: “It’s a triple win.”

Learn more about emergency room services at RWJBarnabas Health hospitals, or view all of our hospital locations to find one that is nearest to you.