Building a Better Model to Provide Effective and Efficient Care in a Busy Emergency Department

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The new concept, called AcceleratED Care, guides nearly 25 percent of less-urgent patients into a process where they can be assessed and treated by ED providers more quickly.  

The goal is to keep patients “vertical” and moving through the various phases of the ED including lab diagnostics, imaging, and treatment. The project is a significant opportunity to expedite patient care and reduce length of stays in Utah's busiest ED and Level 1 Trauma Center.  The reduction in time for a patient’s ED visit will also lead to a better patient experience in our emergency department.

In the ED, we try to see all patients as quickly as possible – always prioritizing the sickest patients. Traditionally, this has meant patients with less-severe illnesses have to wait longer to be seen. On busy, high-volume days the waits can be aggravatingly long and the patient experience suffers. 

Our goal is to avoid the scenario where a patient walks into Intermountain Medical Center, sees the chaos of a busy waiting room, and decides to leave and seek care elsewhere. We don’t want patients who might have stroke or heart attack symptoms walking out due to long waits. Delays in care of these serious conditions can lead to worse outcomes.  

The goal of AcceleratED care is not only to expedite care for the less-urgent ED patients, but all ED patients regardless of their symptoms or illnesses.

We attacked these problems with patient flow through intensive work with a fantastic and motivated team of physicians, nurses, staff and administrators. Two of our goals were, first: to reduce the length of time patients stay in the ED and reduce total bed occupancy — so we’d have more beds free to take care of the sickest patients more quickly — and second: to monitor patients who needed a more lengthy workup, but didn’t necessarily need admission to the hospital. 

We were able to meet our goals by employing two new ideas that are gaining traction in the world of ED operations: vertical patient flow and the “swarm” approach to patient assessment.

Vertical patient flow is based on the idea that not all patients need to lie down in a bed in a private room to get their care. 

Many problems — a dislocated finger, a sprained ankle, or even some kinds of chest pain, for example — can be treated more efficiently by assessing the patient in a private area, then moving the patient to various diagnostic and treatment areas where they can be seated in a chair — eliminating the need for a bed. These vertical patients get a much more active sense of movement toward a goal. Before AcceleratED Care was implemented, we estimated that we could move approximately 25% of our patients through this type of model.

The “swarm” approach to patient assessment is a redesign of the traditional “triage first” system of evaluation in the ED. Under the old system, the patient would be seen first by a nurse, who’d take a history and vital signs, and later by a physician, who would often take the history again. 

This often led to delays and frustration as patients answer many of the same questions asked by the doctor and nurse in different areas. With the swarm approach, the patient is assessed by their entire care team at once: a nurse, a physician, and sometimes a tech. The physician can take the history while the nurse takes notes, and at the end of the assessment the whole team, including the patient, knows the plan of care. 

To implement this new approach to care, we repurposed an existing space in the ED — transforming three existing triage rooms into intake spaces for evaluation and treatment of simple complaints — and constructed a fourth room out of a waiting space.  We took six of the closest rooms from the main ED and designated them for AccerlatED Care patients who’d temporarily need a bed for a procedure or an exam. 

We then created a "results waiting" area with comfortable medical recliners where patients could wait for the next step in their care. The ED physician group added provider hours in the form of a nurse practitioner and two physicians to staff the model from 10 a.m. to 10 p.m., our busiest time in the ED.

Thus far, the model has proven very effective. Two months after implementing this model, we’ve been able to reduce the overall length of stay in our ED by approximately 20 minutes (a 10% reduction!), and we’ve dramatically reduced the number of patients who leave without being seen.

One tool that’s proving helpful is a set of complaint guidelines that suggest a standard workup for common diagnoses such as abdominal pain, back pain, headaches, or sore throats. These include criteria that help guide which patients should be seen in AcceleratED Care and which should be seen in the traditional ED (now called “AdvancED Care”). 

For example, a patient who presents with abdominal pain would be routed to AdvancED Care if he or she is over 50 years old, has had a recent surgery, or has other medical complications.

Occasionally patients initially directed to AcceleratED Care are sicker than they initially appeared to be or need access to more diagnostic testing; these patients are moved into the AdvancED care track, where more time can be spent on their workup and treatment. On the other hand, there have been more serious patients treated effectively in AcceleratED Care. 

The other day we assessed a patient in AcceleratED Care and ended up admitting that patient directly to the ICU. That happened to be the fastest and most effective way to treat that patient that day, and the process worked well. We’ve also seen AcceleratED Care help us better manage large patient surges, something that occurred frequently during the holidays. 

On Christmas Day, for example, we had 80 patients arrive in a four-hour period — and only two out of 251 patients walked away without treatment that day.

As physicians, we absolutely love working with a small, efficient team of motivated nurses and techs who really shine in this setting — providing quick, compassionate care. We hope this intense teamwork experience rubs off on all of us and builds the culture of teamwork in the main ED as well.

So far the reaction from patients has been very positive. Though we don’t have formal data on patient engagement yet, the initial feedback has been that patients love to be seen quickly and move through their care efficiently. One gentleman with a laceration to his finger remarked, “Man, you guys are fast. I was over by the vending machine getting a soda and thinking I’d be waiting a while when my name was suddenly called.”  

The physician treating the gentleman described the new process of AcceleratED care versus the old congested waiting room and the patient said, “Well, you guys are great and this new way is so much faster.” 

We’re hoping to glean more information from the patient engagement surveys and we’re looking at other options as well, including creating a kiosk in the ED where patients can give real-time feedback.

We’ll continue to refine and expand the model for AcceleratED Care to make it as effective as possible, but we’re pleased with the results so far. It’s been a great learning and growing experience for our care team. We see opportunities to apply this model to other processes in the ED, as well as other busy EDs in the Intermountain Healthcare system.