Quick, name that game?
Yes, it’s Monopoly and those who know me or knew me in my childhood and young adulthood know how much I love that game. In 8th grade I did a report on it and figured out that it was named for streets in Atlantic City and I even know the most frequently landed-upon property… but more on that another time. What does this have to do with the ED you wonder? Well, read on…
In this Unexpected Experience series we’ve been looking at what’s most important to patients and families when they come to the ED (i.e. not waiting) and how we can reduce the waiting for them by improving their flow through the department. Just like in Monopoly where everyone wants to get to “Go!” our patients and families want to get the care that they need and then get back home.
To improve patient flow, we’ve looked at a few foundational strategies for improvement with a Lean process approach and standardization of key processes. In this blog, we’ll take a look at three additional strategies that many organizations are using to help improve their flow and manage the wait times for patients and families.
Immediate or Direct Bedding
This strategy bypasses the typical triage process and aims to place patients in beds as soon as they arrive, if beds are available. Patient registration is done at the bedside as soon as patients receive an armband identifier, similar to patients who arrive via ambulance. Many organizations combine this strategy with a component of “Physicians First”. This means utilizing an approach where a nurse and a doctor do an initial patient screening in triage once the patient has an identifier and any blood draws have occurred. This can be as brief as a 90-second interaction where the physician is able to move quickly between patients triaging based on acuity and placing initial orders for tests. This is a particularly helpful aspect in those instances when there are no beds available for immediate bedding.
This is a model that has gained popularity in recent years as many EDs are adopting it with the goal of shortening the time before a patient is seen by a physician or care provider and helping to decrease the overall length of time spent in the department. The model works by creating a second flow or stream of patients through the ED that runs parallel to the more acute/critical care flow stream. This parallel stream is for patients with less complex problems such as a laceration that needs suturing or a pregnant woman who is vomiting. This is different than a “fast track” or “quick track” type of scenario; many EDs that are doing split flow also operate a “fast track” to handle their lower acuity patients with cold-like symptoms but no fever, ear pain, dental pain, etc. If you’re familiar with the ESI or (Emergency Severity Index) in an ED, think of a quick track as handling more 4’s and 5’s and a split flow pod serving the “Vertical 3’s” – the less sick 3’s who are stable but need some treatment.
Most EDs who have incorporated a split flow model use some form of a “pivot nurse” or “flow coordinator” who sees patients immediately when they enter the ED. This nurse makes an initial evaluation and directs patients to the appropriate level of care, be it acute/crucial or the less complex. Some organizations have even identified certain areas of the department that operate for this second flow/stream of patients and they will flex it open for certain times of the day or days of the week per higher demand. Another characteristic of some split flow models is an “all hands on deck” approach where the patient is roomed and is seen by a nurse and a mid-level provider at the same time so as to expedite the care and treatment. The general goal is that their work up won’t exceed 2-3 hours so that they are not tying up a bed, however if the patient’s acuity and level of care requires it, they may be transferred to another level of the ED for care.
Triage as a Function…Not Just a Location
Both of these models require that we think about triage as more than a location in the department. As mentioned in the “Physicians First” component of the immediate bedding model above, many organizations are providing the ability for patients and families to see a provider early on in their journey, often in triage. I once shadow coached an ED physician who had a version of this as part of her process. She made it a habit to go out into the triage area and at minimum greet the patient (hint: huge patient satisfier) and she was also able to do her own rapid visual assessment prior to seeing that patient in the treatment area. That way she could also instruct the rest of the triage team if a specific course of action was needed prior to taking the patient to the treatment area.
Additionally, initiation of treatment protocols as part of the triage process is another great way to help the patient get “in process.” Having them have labs drawn, leave specimens, etc. per protocol can help to get those tests underway so that providers are more easily armed with results by the time that they are seeing the patients.
Each of the strategies we’ve covered in these last two blogs has focused on departmental activities that organizations may incorporate at more of a macro level. We started with a Lean process improvement approach and looked into standardization of processes, immediate or direct bedding, split flow, and triage. In the next blog in this series we’ll begin to look at what individual staff and providers can do to help manage the wait with patients and families on their Unexpected Experience.
Special thanks to Daisy Nelson and Nicole Braegelmann for their contributions to this blog.
Are Split Flow and Provider in Triage Models in the Emergency Department Effective in Reducing Discharge Length of Stay?
Pierce, Beth A et al. Journal of Emergency Nursing, Volume 0, Issue 0. Retrieved: http://www.jenonline.org/article/S0099-1767(16)00047-7/abstract
The Role of a Split-Flow Model in the Improvement of Emergency Department Efficiency with Respect to Patients Presenting With Different Acuity Levels
Joseph, A. et al. Annals of Emergency Medicine, Volume 62, Issue 4, S1 – S2. Retrieved: http://www.annemergmed.com/article/S0196-0644(13)00968-2/abstract
7 Tips for Improving Emergency Department Patient Flow
Angie Esbenshade, Stephanie O’Bryon, and Wenzel Tirheimer. Oct 19, 2015. Retrieved: http://www.hfma.org/leadership/immediatebedding/
‘Immediate bedding’ boosts patient satisfaction at California emergency department
Perform Improv Advis. 2003 Dec; 7(12):155-7, 153. Retrieved: http://www.ncbi.nlm.nih.gov/pubmed/14748129
Immediate Bedding and Patient Satisfaction in a Pediatric Emergency Department
Flood R1, Szwargulski P2, Qureshi N1, Bixby M2, Laffey S1, Pratt R2, Gerard J1. J Emerg Med. 2016 May; 50(5):791-8. doi: 10.1016/j.jemermed.2015.10.008. Epub 2015 Nov 11. Retrieved: http://www.ncbi.nlm.nih.gov/pubmed/26577525