Emergency department crowding has become one of the defining operational challenges facing US hospitals, with rising patient volumes, prolonged boarding, and staffing shortages contributing to long waits for care. 

At RWJBarnabas Health, a 12-hospital health system headquartered in West Orange, New Jersey, leaders decided the answer wasn’t building larger emergency departments or hiring more clinicians. Instead, they redesigned how patients move through the department — from arrival to admission — using standardized workflows, rapid room placement, and tighter coordination across the system.

The operational changes have translated into measurable improvements across the health system. 

“We’ve consistently reduced arrival-to-provider times across the system, with patients now typically seeing a [health care] provider in under 20 minutes, and at some locations in under 10 minutes,” said Christopher Freer, DO, executive vice president and chief clinical officer of Acute Care Providers at RWJBarnabas Health. “Our systemwide rate of patients leaving without being seen is below 0.5%, and patient satisfaction scores are the highest we’ve recorded.”

Freer said that RWJBarnabas also reported a 43% improvement in the time from admission order to departure from the emergency department between February 2024 and May 2026, while the time from inpatient bed assignment to ED departure improved 38%, from 68 minutes to 42 minutes. Those gains occurred even as emergency department volumes increased year over year.

Emergency department crowding remains a complex problem driven by many factors outside the emergency department’s control, including inpatient bed availability and hospital capacity. But RWJBarnabas Health leaders said their experience suggests that standardized workflows, clearly defined roles, and coordinated communication can substantially improve patient flow without requiring major capital investments, offering practical lessons for health systems looking to improve emergency department throughput.

A Systemwide Challenge

Freer said the initiative grew out of the operational strain emergency departments nationwide experienced following the COVID-19 pandemic.

“Patients were frustrated by the resulting long wait times, and our teams were working hard within protocols and processes that weren’t always most efficient,” he said. “Across our entire system, the operational challenges were the same — regardless of hospital size. That gave us the opportunity to develop a consistent approach that could be implemented across each of RWJBarnabas Health’s 12 hospitals, and ultimately something that other hospitals across the country could replicate.”

Redesigning Patient Flow

Rather than investing in new facilities or major technology upgrades, leaders focused on redesigning the emergency department’s front-end workflow.

“We began by redesigning the front-end process of the emergency department to help patients move into care more quickly,” Freer said. “The model starts with a brief intake by a greeter nurse, rapid assignment to an available room using a pull-to-full approach, and real-time communication with the care team so providers can evaluate patients sooner.”

The redesigned workflow simplified intake, clarified staff responsibilities, and emphasized moving patients into available treatment rooms as quickly as possible.

“We simplified the intake process, moved patients into available rooms sooner, clarified team responsibilities, and improved communication throughout the department,” Freer said. “These are practical workflow changes that don’t require major capital investments and can be adapted by many emergency departments.”

Technology supported the redesign but was not the driving force behind it, Freer said. Instead, RWJBarnabas Health used EPIC to reinforce the new workflow through electronic handoffs and real-time coordination among care teams.

“EPIC was an important part of the initiative because it allowed us to implement electronic handoffs and support the redesigned intake process,” he said. “The technology helped reinforce the workflow we built, including real-time coordination as patients moved through the emergency department. The operational changes came first, and EPIC helped us execute them consistently.”

Freer said the system first implemented the model at Cooperman Barnabas Medical Center before expanding it across all 12 hospitals. Today, emergency departments throughout the system use electronic handoff automation, daily performance scorecards, and real-time operational monitoring to support patient flow.

Nursing at the Center of the Initiative

Cathlyn Robinson, MSN, RN, vice president of nursing operations for emergency medicine at RWJBarnabas Health, said the initiative depended on strong nursing leadership and close collaboration across departments.

“Many of the changes centered on the variety of processes happening throughout the emergency department, where nurses play a critical role in assessing patients, prioritizing care, and keeping patients moving through the department,” Robinson said.

The effort extended well beyond the emergency department itself, she said.

“A pivotal component of our success is having the support of the organization’s leadership,” Robinson said. “It is a partnership between the emergency department and administration to ensure that all departments are aligned and focused on our patients.”

Once the new workflow was established, every team that supports patient care had a role in making it successful. Improving patient flow required coordination across the entire organization, including the emergency department, nursing, imaging, laboratory, environmental services, registration, transport, and other support staff, she said.

Results Across Diverse Hospitals

The results were seen across hospitals of varying size and complexity. According to RWJBarnabas Health, the system’s emergency departments range from Newark Beth Israel Medical Center, which logged more than 101,000 emergency department visits in 2025, to Rahway Hospital, which saw nearly 40,000 visits. 

Robert Wood Johnson University Hospital, a Level I trauma center, cared for more than 80,000 emergency department patients during the same period. According to system leaders, emergency department volumes continued to rise throughout implementation while staff vacancy rates remained low across the system, with many departments reporting no open positions.

Freer said patients most often notice the difference in how quickly they are evaluated.

“Beyond the numbers, patients tell us they appreciate being evaluated quickly and kept informed,” he said. “Staff also describe a more organized workflow that allows them to spend more time focused on patient care.”

Freer and Robinson reported no relevant financial relationships.