“I feel like it is an assembly line”

supertrack flowThis is what several of my coworkers have said about the changes going on in our ACC4 area.  Some background for those that have trouble keeping up on all the changes in our department: ACC4 is the direct descendant of the old NE area started about five years ago.

Its original concept was to take our fast track and staff it with a nurse, an APN, and the physician in triage.  It was intended for low acuity (ESI Level 4,5), ambulatory patients to be seen by the physician up front in triage and have orders placed. The care would be completed by the team in the back.  Its home for many years was the old blood bank donation area with curtains, lounge type chairs, and a small waiting area.  20 patients a day were seen. TATs usually topped 180 minutes (See supertrack numbers – 2010).  Though resource intensive it did allow us to keep a physician in triage and reduce the TAT for low acuity patients.

When we moved into our new home this “fast track” area settled eventually into the five beds in ACC4.  It underwent some modifications including tinkering with virtual spaces (sitting waiting patients in hallways),  using chairs instead of gurneys  and doing pull-till-full (See How Cutting Edge is Your ED Flow? which caused many of the patients to bypass physician initial eval.  Still it was an improvement.  Volume seen increased, TATs decreased (supertrack numbers – 2011).

Now change is happening once again.  ACC4 has a new designation called SUPERTRACK.  What is so super about it? Well first of all it has expanded its focus to also include level 3 acuity patients (though only ambulatory ones with moderate acuity).  Also its goals are super – to move 6 patients per hour through a focused, streamlined process that provides good, safe care expediently.  These are patients with straight forward complaints with very simple diagnostic and therapeutic needs.  Their goals are the same as ours.  Treat me well but treat me quickly.

So to match these straightforward patients we have created a straightforward process (See Flow Map):

  • Abbreviated triage
  • Focused exam by a physician
  • Focused charting by the scribe
  • An emphasis on PO meds
  • A comfortable semi-private waiting area while awaiting diagnostics
  • Private reevalaution, procedure completion and discharge by the APN
lean shopping

Is it a completely rigid process? No.  But it plays to the strengths of each member of the team and the patients should feel the flow as they move through each stage.  What are the advantages?

  1. Every patient is seen quickly (generally less than 20 minutes from arrival by a physician).
  2.  They get out quicker (TAT averages are 120 minutes and continues to fall).
  3. The entire ED benefits by freeing up bed space for those who need them more acutely (frees up 4-6 additional beds for high acuity patients).

So does this change the roles of some team members?  Yes it does.

ED Sign

Do we have to do it?  It depends.  If we want to get the 100 ambulatory, low/moderate acuity patients out of areas needed for higher acuity patients than the answer is yes.  If we want to meet our patients expectations of timely care than yes.

Now getting back to the quote I started with about assembly lines. It is possible to create something of high value (which urgent medical care certainly is) via linear type processes.  Hermes bags are not made by one person start to finish. The great rides at Disney move you like cattle (though you are happy along the way).  A star Chef does not hand create everything that is put on your plate.

Each of these processes have team members who are highly trained and work well and closely together. In order to provide high quality care, healthcare will have to become better at team work.


Muda – Japanese for Waste. See previous posts for more details.