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The Wal-Mart ED: Higher Volumes Mean New Paradigms

Welch, Shari J. MD

doi: 10.1097/01.EEM.0000307639.37007.36
Quality Matters

Dr. Welch is the quality improvement director in the emergency department at LDS Hospital in Salt Lake City, a clinical faculty member at the University of Utah School of Medicine, faculty at the Institute for Healthcare Improvement and the Urgent Matters Project for the Robert Woods Johnson Foundation, a quality improvement consultant to Utah Emergency Physicians, and a member of the Emergency Department Benchmarking Alliance.



In the 1980s, the average emergency department saw 17,000 ED visits a year (50 patients a day). The processes, operations, and cultures that developed were appropriate for these volumes. Physicians could work 24-hour shifts, and expect to sleep part of the time. Nurses worked 12-hour shifts, and brought their knitting projects. Single coverage by physicians was the norm. Communication took the form of verbal orders from the doctors, and department flow was managed by intuition. All of these practices are now relics of another era.

The average emergency department now sees 40,000 visits (more than 100 patients a day). As Jim Augustine of the Emergency Department Benchmarking Alliance likes to say, “There are no more 7-Elevens. We are all Wal-Marts!” Apropos of this new reality, several paradigm shifts have occurred. The smooth and efficient functioning of the Wal-Mart ED requires changes worth noting. It is well known that as volume increases, an ED's operations need to change. Most departments find at 20,000 volume, operations need to change significantly. “The way we've always done it” doesn't work once an ED reaches 20,000 visits. Higher volumes generally require zoning, patient segmentation, standardized order sets, computerized tracking systems, and a focus on communications. A vision of service quality, efficiency, and safety must be iterated and embraced at all levels of the organization.



Many newer EDs which anticipated more than 40,000-visit volumes were designed to operate as separate hubs. Both the pod designs of the 1990s and the newer I-beam designs of this decade have critically located workstations that allow the centralization of staff and supplies (techs, charge nurse, meds, computers) in one workspace, and are designed to accommodate roughly 20,000 ED visits. Beyond this volume, the sheer amount of information and tasks to be managed is untenable without sacrificing safety and efficiency. Some large EDs function as mirror-image departments with some variation. For instance, Zone A might have critical care patients and the main ED, while Zone B encompasses the fast track and some main ED patients.

The staffing of the zones can be variable: From primary care nursing and free-range patient assignments for physicians to zone nursing and physician assignments, the most important aspect is that the care of patients in one zone involves one set of staff who are responsible for that geographic space. The charge nurse polices the zone for inefficiencies, backlogs, and delays. Communication is easier, and the workload is manageable.

A word or two about the concept of workarounds. ED folks are an industrious lot. When faced with an operational problem, they will improvise a solution. The problem is this workaround may be inefficient and help to build out bad processes. For instance, at a recent opening of a large western medical center, I observed that the communication systems were flawed. The voice recognition-based radios were technically unreliable, and the phones were difficult to use when trying to pick up an outside call. Eventually the ward clerk got frustrated with trying to get calls to his emergency physicians.

He began this workaround: Every time an attending call came in, he would leave his desk and phone, run to the physicians' work area, tap the physician on the shoulder, and retrieve the call for the physician. This is a desperate example of a workaround which if left unaddressed will create an ad hoc bad process. It is inefficient, cumbersome, and leaves the desk unattended so other calls may be missed, and it is the sort of workaround that ED staff come up with in response to glitches in the workspace.

The flawed temporizing measure becomes a standard process over time by default. Most EDs are fraught with bad processes that develop out of workarounds. Bad processes get laid upon bad processes until patient flow is a never-ending maze of workarounds, delays, and inefficiencies. Patients occupy beds for hours while nothing of value is added to their stay. For some departments, the only solution is to reinvent patient flow at the subcycle and operational level.

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Segmentation and Standardization

By identifying patients with similar needs or anticipated lengths of stay, patients can be segmented out for improved efficiency. Once upon a time, the ED was an ER, usually a single treatment room in the basement of a hospital. As utilization grew, the footprint of the ED grew, and by the 1980s most EDs had discovered that minor injuries could be separated out from the department and with the right resources could be treated-and-streeted in a more efficient manner by creating a fast track for high census times of the day.

In the 1990s emergency physicians at higher volume centers found that some patients needed 24 hours to be diagnosed, treated, and discharged. This was the heyday for the ED observation unit (still a great concept). Segmentation has come along with work being done by the Institute for Healthcare Improvement's yearlong ED Innovation Community. A number of EDs across the country have been improving service lines by employing even more segmentation.

Variation in practice between doctors and nurses leads to inefficiency and safety problems. By standardizing processes, operations, and some basic order sets, you enhance both safety and efficiency. For instance, if the department chooses one anti-emetic to be given for vomiting as a default order, the nurse does not need to find the physician to get an order, and she does not need to remember which physician likes which anti-emetic. The staff becomes familiar with dosing and side effects of the drug that has advantages in terms of patient safety. Processes like urine collection, preparation for imaging (CT with oral contrast, bladder filling for pelvic ultrasound), and preparation for suturing also benefit from standardization. Standardized orders and checklists can help achieve this.

By the time an ED reaches 40,000 visits a year (more than 100 patients a day), the white greaseboard needs to give way to a computerized tracking system. The sheer amount of data to be managed is impossible without this type of technology support, but let the buyer beware! There are systems that are cumbersome and actually impede workflow. The best systems are intuitive, designed with the centrality of workflow in mind, and provide adequate and effective cueing functions and real-time data dashboards that inform staff about the status of ED operations. Practitioners need to be thoughtful in their selections of a tracking system and try to influence their administrators to purchase a system that will serve but not impede workflow and will support quality improvement activities.

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Low-volume emergency departments can operate with verbal communication systems and handwritten charts. For the Wal-Mart ED with a larger footprint, greater numbers of staff working, and double and triple physician coverage, the verbal order models cannot be sustained. Between 20,000 and 40,000 visits, communications involving two-way radios, Voceras, and cueing through a whiteboard or tracking system make for efficient communications. Running around a department to find staff to give verbal orders is very inefficient.

By 40,000 visits, the department will likely find radio calls, overhead paging, and even Voceras are too noisy and create high-decibel background noise. Cell phones that can receive directed important calls from other attending physicians, though expensive, provide the safest and most reliable communication. The physician can carry this with him and receive communication directed only to him.

A word about short-term memory and communication logistics: The average person can only carry seven items in his short-term memory. The busy emergency physician is working in the department and carrying the name of the patient he needs to talk about, the name of the attending he is waiting to hear from, a reminder from a nurse to check the labs on another patient, etc. For many busy ED landlines at larger hospitals, the lines are identified with four, five, or six digits. When the ED clerk overhead pages, “Dr. Smith, your call from Dr. Jones is on line 2-4-5-3-2,” the chances that the physician will reliably remember and retrieve these numbers without another prompt is actually quite low. A simple fix is to label these lines with single digits or even letters to enhance the likelihood of successful memory retrieval. This is a quick fix!

Communications in a large emergency department is one of the biggest challenges to smooth and efficient operations in the ED. Goals for your communications should include targeted communication, overhead announcements, reliable systems, and perhaps cell phones for physicians.

The high-volume Wal-Mart ED poses new challenges and requires innovative thinking. Acknowledging the changes that occur as incremental volume increases are reached and designing your operations and processes to accommodate these changes needs to be done thoughtfully and methodically.

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  • Get the right information to the right individual using targeted communication.
  • Avoid communication systems that involve increased overhead noise for the department at large.
  • Choose systems that are intuitive and reliable.
  • Consider hybrid systems with cell phones for physicians and radios for nurses.
© 2008 Lippincott Williams & Wilkins, Inc.