ER outside

Part One of Anatomy of a Super ER started with the morning ritual of change of shift and set the scene by highlighting what Paterson ER has to offer in terms of space, staff and technology.

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Part Two will follow the action of the day highlighting the processes in place to treat a large number of patients efficiently while also ensuring that those with specialized needs get cutting edge care.

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ED blueprint

ED Treatment Areas

By 11 am all 100 treatment areas are open. Until well past midnight all these beds will be in nearly constant use. In a perfect world some beds would always be open for incoming patients. But the world is rarely perfect.

 

Beds typically will remain empty for only as long as it takes for the first patient to leave and the next patient to be moved into it. At times demand will exceed this capacity anywhere from 10-40% (11-14 patients for every 10 beds). Configuring operations to be lean and efficient are key to handling the constant demand.

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CAPACITY / DEMAND

ed-signPatients arrive to the ED by different methods but enter only one of two ways : through the waiting room or the ambulance entrance. The majority (85%)  will “walk in” and present to the triage desk in the waiting room. However, critical patients will be included in this flow of humanity. Nearly 1/4 of all heart attack and stroke patients along with a smattering of patients with gunshot wounds will “walk in”.

 

TRIAGE was created as a way to “sort” patients and then expanded to capture relevant and mandatory data. This expansion beyond the purpose of sorting has made “traditional” triage time consuming (5-10 minutes per patient) and a major bottleneck. Patients can end up waiting to complete triage even when a treatment bed is open.

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In order to meet the demands of the up to 30 patients an hour who are arriving, Paterson ER has been re-engineered to streamline care. Paterson ER has a PIVOT or abbreviated triage  that is conducted within 10 minutes of arrival.

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This brief evaluation (age, chief complaint, heart rate and pulse oximetry) gets back to the basics of sorting the patients by acuity but also goes a step further and assigns patients to specific queues. Even though it takes about a minute to complete the accuracy of acuity and location assignments are very high.

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A second part is ensuring that the patients’ needs match the workflow of the area they are sent to. This means trying to keep the patients who can remain ambulatory and upright out of beds that have average lengths of stays in the hours.

supertrack flowMost ambulatory patients are treated in our Supertrack. The physicians and nurses in this area are focused on patients who can walk and generally only need 1-2 tests/treatments. A good example would be patients with complaints of localized injuries (cuts, joint pain, wrist fractures) or limited medical complaints (moderate asthma, viral symptoms, etc). At Paterson ER this enables a 9 bed treatment area to have 15-18 patients in process. The creation of virtual beds reduces time to be seen by physicians and total length of stay. The average patient in Supertrack is in and out in under 100 minutes.

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SUPERTRACK – Similar to the concept of the Fast track where patients with noncritical complaints are sent for care with the idea of keeping them out of the Main ED and speeding their care. In the Supertrack patient are seen in private treatment areas but then moved to internal waiting areas while awaiting tests to be completed. Currently over 100 patients a day are treated and discharged from these areas.

 

mc-1119l-l1doctorrstOf course some patients need the opposite of this. They need more monitoring and time. One of these groups are elderly patients. The 20 bed SrED (Senior or Geriatric ED) cares for the majority of patients over 65 years old. While the needs of this group are tremendously variable there are some commonalities. They need more extensive examinations and history taking including a review of all medications.The probability of serious illness or injury is also much greater.

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Seniors tend to benefit from a quieter and better lighted area as well as thicker mattresses to prevent pressure injuries. The SrED staff has received special training on the care of these high-risk patients. With the help of this dedicated area the average door to doctor time for Seniors is between 15-20 minutes.

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Lives Saved While You Wait

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The majority of patients seen on this day will go home (nearly 90%). However some will arrive in critical condition and need immediate life saving interventions. For them any amount of delay can be deadly (SEE Code Black). These are the patients that emergency nurses and physicians live for. Their care is based on the single minded belief that you put yourself next to the critically ill/injured patient and treat them aggressively. The resuscitation of a critical patient is a full contact sport.

04a_t607Rarely is that team composed only of emergency department personnel. Frequently what the patient needs must be drawn from the expertise of the entire hospital (SEE trauma team). This care must be coordinated and time compressed. The immediate goals are stabilization of the ABCs (airway, breathing and Circulation) with preparation for definitive care. [That definitive care includes cardiac catheterization for patients suffering heart attacks and emergent surgery for select traumatic injuries]. As many interventions as possible are performed simultaneously. For those involved time stands still and attention narrows only to this one patient.

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tt-positions-greenTRAUMA TEAM – Several times a day a page goes out “TRAUMA ALERT ADULT ED”. This summons a large group from within the ED and across the hospital. The team is led by a board certified trauma surgeon and includes an emergency physician and resident (critical for airway management), surgical residents, ED nurses and med techs, respiratory therapists, and radiology techs (xray and CT). The activation of the trauma team also puts a CT machine on hold, blood products on standby for emergency transfusions, and alerts the OR staff of the possibility of an emergent case (one OR is always on standby).

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The transition from day to night will see the same cycle. Patients come and go. Handoffs between staff attempting to make care seamless. Towards midnight the pace of incoming patients begins to slow and areas that opened at 8 am or 11 am  are now closing down. By four am only a few patients will appear as the night team finishes up the care of their patients. 7 am is just around the corner when the day will start all over again….

7 clock

 

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Written by:

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David Adinaro MD, M.Eng., FACEP

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professional david adinaroDr. Adinaro is the Chief Medical Information Officer and Patient Safety Officer for St. Joseph’s Healthcare System in Paterson, NJ. He remains active as an emergency physician in the Paterson ER. Dr. Adinaro can be reached via  @PatersonER .

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This publication represents the personal opinion of the author and does not reflect his employer.