“A system works exactly how it is designed (or allowed) to work”

supertrack flowT

Here in Paterson change in process has been a constant companion. But why frequent change? Shouldn’t we expect to get this right one day???  The reality is we are getting it right. In 2005 our ED handled 70,000 visits with an unenviable walkout rate of 8%.

By 2012 our volume had doubled (140,000 visits) and remarkably walkouts fell to 1.5%. Much of this success is due to increased staffing, more beds,and a good EMR system (MEDHOST). That is not all though,  it took the creation of proper processes (how things should be done) and my hard-working colleagues (who get the work done everyday) to achieve these goals. Most importantly the department has embraced change and staff are active in making new processes work.  As we continue to grow (projected 150,000 visits in 2013) my goal is to get walkouts below 0.5%.

What follows is a list of commonly cited methods for increasing patient flow along with my take on them.  They are related to similar themes which are eliminating waiting, bypassing typical bottlenecks,  and moving processes that do not add value off to the side.

FLOW 101 (focus on modifying the traditional triage\front end processes)

Bedside Registration:

Truly FLOW 101. A basic step that puts the patient one step closer to doctor\nurse  who will be seeing them. By moving registration completion “indoors” it cannot act as a bottle neck to slow down flow. It can be completed during the wait periods that all patients go through. Importantly for us this is coupled by a great front-end quick reg process that secures the patient in the EMR (MEDHOST) and facilitates patient flow.

Advanced Triage

RNs instituting standard orders for certain types of complaints (xray for ankle pain, pregnancy test for abdominal pain, cardiac order set for chest pain). The goal is to get ordered the critical\common tests that the patient is going to need and would be ordered later. From a physician point of view knowing the UCG before you walk into the room of a woman with belly pain is a great help.

Team Triage

This is an imprecise term but generally refers to a physician joining  the triage team. The advantages are earlier door to doc times, more advanced orders, and help sorting  some of the more subtle cases. All of these do lead to some improvement in turn around time (TAT).

However it comes at a cost of duplication (two docs see the patient), possible over ordering, and can actually slow down a traditional triage process. I feel this is a very last decade concept that will be replaced with other methods that get the patient to one primary physician more quickly (See Advanced Patient Flow section below).

FLOW 202 (intermediate steps that begin to break down traditional triage\front end operations)

Abbreviated Triage (Pivot Nursing)

What is the real purpose of triage? Initially it was developed as a method to sort incoming patients and determine who should be seen next. Over the years it has taken on more and more functions. Now besides obtaining info to help in sorting (chief complaint, vitals) triage is now expected to obtain near complete medical information including meds, allergies, screening for risks, pmh, social history, etc. All this information is important but does not help in sorting sick from not sick.

Abbreviated triage gets back to the essence of the process. It is a brief nursing intervention that is designed to sort patients from those who need to be seen immediately (facial weakness) from those who can wait safely (toe pain, toothache). It is fast (one minute or less) and relies on just basic information:  chief complaint, minimal vitals (pulse and pulse ox) and nursing assessment.

Pull-to-Full

For much of the day (before 11am and after midnight) most EDs have empty beds. Pull-to-full places the emphasis on getting the patient (triaged or not) into that bed and closer to the team who will be caring for them anyway. When beds are available sticking with a traditional triage process adds no value to the patient and delays care. Like abbreviated triage this valuable step requires some change in the culture of the department but leaves the general structure of a traditional ED intact.

ED Sign

FLOW 303 (advanced steps that change the structure of back end operations signficantly)

Supertrack

Building on the quick sorting of patients using Abbreviated Triage are changes to the structure of the department to maximize the number of Vertical Patients (those not needing constant monitoring or to lie in a bed during treatment) cared for in the minimum of beds.

Supertrack in many ways is simply a more advanced version of fast track. Ambulatory, very low acuity patients who need only 1 or 2 resources (an xray and one dose of meds, xray and sutures) are sent there directly after Abbreviated Triage. By cohorting them in one area and placing an emphasis on virtual space (think chairs in a waiting area) you can easily move 4 or more patients per hour with one physician\nurse team probably augmented with a scribe and a tech.

Split flow (LEAN TRACK)

This is probably the most radical change to the structure of emergency departments. Capitalizing on effective Abbreviated Triage patients with moderate acuity (ESI Level 3) though able to be ambulatory are seen in a segregated unit. This unit has a streamlined process that includes initial evaluation by the physician\nurse team, waiting in a semi-private area with chairs, and after completion of testing a structured reevaluation and discharge. A team led by a physician with two nurses and a tech should be able to average 3- 3.5 patients per hour. This frees up significant bed space for more acute and  nonambulatory patients.  My limited experience suggests that nurses are able to identify appropriate patients who are unlikely to be admitted (< 5%)  or require emergent treatment.

HOSPITAL FLOW (to improve ED flow)

The ED is just one part of the hospital (obviously the most important 🙂 ). ED flow tends to improve when hospital  flow is managed throughout the institution. I don’t have room to go into detail here but wanted to provide you a list of some of the concepts used outside of the ED

  • Forecasting admissions – historical vs. real time
  • Admission orders
  • Hospital Bed Tracking computer systems
  • Management of Demand\Capacity