Hackensack University Medical Center’s pediatric emergency department has significantly reduced patient wait times and its left-before-treatment-complete rate through a series of targeted patient-flow improvements.
In 2022, patient volumes hit a record high at the pediatric ED — part of Joseph M. Sanzari Children’s Hospital at Hackensack (N.J.) University Medical Center. The waiting room was routinely full, and many lower-acuity children were not getting in front of a provider in a timely manner.
“We were simply in survival mode, focused on ensuring everyone who comes through the door is cared for as safely as possible,” said Alice Kazekjian, MSN, RN, director of the nursing emergency trauma center, pediatric ED, and observation units for Hackensack University Medical Center.
After navigating a sharp spike in pediatric visits during the 2022 virus season, ED leaders conducted a deep dive into their metrics. At the time, the average door-to-provider time was 50 minutes, and the average door-to-bed time was 52 minutes. Additionally, 4.5% of patients left the ED before completing treatment.
Leadership recognized an urgent need for improvement — especially given that Hackensack University Medical Center’s adult ED, one of the busiest in the nation, was performing significantly better.
The adult ED had something the pediatric ED did not: a fast-track treatment area for lower-acuity cases,and serving about 100 patients a day. Recognizing that many pediatric patients presented with lower-acuity needs, particularly during flu season, leaders identified a key opportunity to replicate the fast-track model.
To enact the model, the hospital formed a multidisciplinary committee composed of physician and nursing leaders, along with front-line team members. The group repurposed a portion of the ED, previously used for outpatient services, into a dedicated fast-track area and secured the necessary resources and equipment.
The pediatric ED also adjusted its physician staffing strategy to better align with season volume trends, according to Virteeka Sinha, MD, medical director of the pediatric emergency department at Hackensack. With support from its informatics team, ED leaders developed dynamic staffing models that increased physician coverage during high-volume winter months and scaled back in the summer, replacing the previous uniform, year-round approach. This flexible staffing model extended to nurses, who could shift between the main ED and fast-track area based on patient demand.
After recognizing that about 30% of patients presented with lower-acuity needs, ED leaders expanded fast-track coverage to 24 hours.
“We understood that we had to increase our fast-track hours and staffing to address the burden of increased volume,” Dr. Sinha said.
By 2024, the pediatric ED was still operating under intense pressure, with 43,200 annual visits — just 3.5% below its 2022 peak of 44,764. Yet despite this sustained demand, the department achieved major operational gains.
The results were dramatic: Door-to-bed time fell 73% to just 14 minutes, while door-to-provider time dropped 68% to 16 minutes. Most notably, the rate of patients leaving before treatment completion decreased by 82%, reaching just 0.8%. The team is now targeting a rate below 0.5% this year.
In 2024, the pediatric ED also received the Lantern Award from the Emergency Nurses Association, partly due to the success of its fast-track initiative.
To sustain these improvements, leaders implemented multiple daily checkpoints with ED team members. Each day begins with a strategy huddle in the early morning, followed by interdisciplinary rounds at 9 a.m. and a midday huddle at 3:30 p.m. Dr. Sinha has credited this regular communication and collaboration among ED stakeholders as a key factor of success.
“An ED cannot be run by physicians or by nurses alone,” she said. “You have to work together.”
According to Ms. Kazekjian, team engagement and transparency have been equally vital. Leaders share weekly performance data with front-line staff via newsletters and visual huddle boards, encouraging ownership and healthy competition. For example, charge nurses track who maintains the lowest walkout rates during their shifts, reinforcing pride and accountability.
“We all recognize our shared objective,” Ms. Kazekjian said. “We aim for our department to excel and to become the best ED in the nation. Our collective goal is to provide the highest quality care to every patient who enters our department.”
