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The ED of Today Morphs into the ED of Tomorrow

Welch, Shari J. MD

Emergency Medicine News: May 2008 - Volume 30 - Issue 5 - p 23
doi: 10.1097/01.EEM.0000319598.71332.95
Quality Matters

Dr. Welch was the quality improvement director in the emergency department at LDS Hospital in Salt Lake City for 10 years. She is on the faculty at the Institute for Healthcare Improvement in Boston and speaks internationally on emergency department quality improvement. She also has served as a quality consultant for VHA, is a member of ACEP's quality improvement and patient safety section, and is a member of the Emergency Department Benchmarking Alliance. She has been published in numerous journals, and just finished her second book, “Quality Matters: Creative Solutions for the Efficient ED” to be published by Joint Commission Resources Publishing.



St. Jude Medical Center in Fullerton, CA, is trialing a model dubbed the “Doc Track” under the leadership of the Institute for Healthcare Improvement, and as I said last month, that has met with early success. The physician does a quick assessment and decides who needs to come straight back, who can go to the fast track, and who can have a workup started and go back to the waiting room until the results are ready. In this model, patients are quickly assessed by a physician, and a care plan is started, though the patient ultimately may be assigned to another physician.

Another facet of the Doc Track is in the discharge process. It is worthwhile to remember these statistics: The average ED now sees more than 100 patients a day. If more than 80 percent of them will be discharged, this means 80-plus patients will be leaving the ED. What could be done to expedite this? How about preprinted discharge instructions, an ED phone system to allow patients and their families to schedule follow-up studies and appointments before leaving the department, “to-go packets” (instructions, medications, and supplies to get the patient through the first 24 hours), transport vehicles, discharge teams, discharge kiosks, and adjacent pharmacy services? All of these are innovations and ideas to facilitate the rapid outflow of patients from the department, and ought to be on everyone's radar and in their future redesign plans.

Other teams in the ED Collaborative have had success with similar models. Florida Hospital created a LEAN track, and Providence Hospital is working on its RAZ (rapid assessment zone) project. It is important to see that these innovations can be adapted in different departments across the country with varying footprints and real estate and still yield success.

Now for a process model completely outside the box: This complex idea is different from anything you have heard about before and is quite possibly brilliant. The process was designed at Mary Washington Hospital in Fredericksburg, VA, for managing Level 3 patients by building on some of these earlier principles. This process has been dubbed “RATED ER” (Rapid Assessment, Triage, and Efficient Disposition of patients in the Emergency Room). For a four-year period, Mary Washington experimented with various intake models including permutations of the physician in the triage model. Their vision was to develop a process for managing the most difficult and largest patient segment: semi-urgent patients. These patients may need admission, but it takes some diagnostics to flesh this out.

In most EDs, this patient subset has no developed or defined processes, and he can often have very slow throughputs. The walking wounded are segmented into a patient flow stream through the fast track with efficiency and the critical care low ESI patients (1 and 2) are quickly treated with AMI and stroke protocols and the like. What of the nonspecific chest pain and abdominal pain patients? Few departments have addressed the needs of this patient segment. At Mary Washington Hospital, the RATED ER process was built out. This model involves assembling two teams consisting of a physician, a midlevel provider, two RNs, a paramedic/tech, two scribes, and a health unit clerk. Each team staffs a five-bed zone adjacent to triage with each team member performing set tasks in parallel.

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Three Patient Tracks

A patient coming to the hospital is welcomed by a greeter, a tech, and a registration clerk. Patient identifiers are quickly entered into the system for the patient, and vital signs are obtained. This process is much abbreviated compared with traditional registration and triage. Just as this intake is finishing, the pivot nurse (an extremely experienced nurse takes on this position of stature in the department) assigns the patient to one of three tracks:

  • ▪Mega-Track (ESI 1, 2): Main ED with traditional high-acuity, high-resource utilization.
  • ▪Super Track (ESI 4, 5): Low acuity and little-to-no-resource utilization.
  • ▪RATED ER (ESI 3) or Tweener Track: Low to moderate acuity with high-resource utilization.

A word or two about this truncated intake process: There are five elements included in this initial assessment to help segment patients up front, including single phrase chief complaint, allergies, pain scale, vital signs, and Emergency Severity Index (ESI). This intake information along with identifiers is obtained in six minutes with two triage/intake sites operating most of the day. This allows the emergency department to do new patient intakes at a rate of one every three minutes. At this rate, Mary Washington Hospital can easily handle their average arrivals of 20 per hour during peak times. The system was designed with exactly this in mind. Nationally the triage process takes between 12 and 20 minutes, and the average door-to-physician times are still 45 minutes. (VHA Data.) This intake process is worthy of consideration as the new best practice.

Immediately after this rapid intake, RATED patients are seen by the team, which assesses the patient together, and the physician iterates to the team what his differential diagnosis is and what his plans for the patient are. Scribes do documentation. The nurse does her full triage assessment, nursing assessment, and begins initial diagnostics and therapeutics. Catheterization for urine, IV placement, and medication administration all begin in an intensive 20- to 30-minute team intake. This intake process was determined by understanding that the system must be able to accommodate 20 patients per hour in order to maintain flow, and with 10 intake beds at 30 minutes each, the system is designed to handle 20 patients per hour. The paramedic/tech draws blood, starts IV lines, and performs EKGs in addition to applying splints and dressings.



There are three possible destinations for a patient after the RATED intake and assessment. If the physician deems that the patient needs ongoing therapeutics, there is a small adjacent ED treatment area for his team to utilize. If the physician deems the patient does not need interventions, he can go to the results waiting area. If the physician deems no further care is necessary, the patient may be discharged from the RATED intake area. By the way, the RATED treatment area consists of eight to 10 treatment beds, two nurses, and a tech. Because most of the intense diagnostics and therapeutics were completed in the RATED intake area, these nurses can carry a slightly higher patient load quite comfortably.

Meanwhile, the RATED team has a system for tracking results and performing ongoing assessments of patients in the treatment area and the results waiting room. When all results are back, the PA (for the treatment area patients) and the unit secretaries or scribes (for the results waiting patients) cue the physician to make a disposition. The physician can admit or discharge a treatment area patient from that bed, while the waiting room patient is typically brought back to a RATED intake bed for final disposition. The team may be carrying 10 to 20 active patients between these two areas while continuing to see new patients. (Could most current ED systems allow a physician to carry this type of patient load safely?)

Mary Washington Hospital knew it had winning strategies, but the data help make the case quite convincing. This department with 100,000 ED visits a year is now a model of operational efficiency. By redesigning the front end with patient segmentation, truncated intake processes, and the radical process changes that they are calling Super Track and the RATED ER model, they are boasting an overall LOS of only three hours, walkaway rates of 1.6 percent, and reduced door-to-doctor times to less than 30 minutes!

The take-home message from the innovators at Mary Washington, St. Jude's, and the IHI ED Collaborative is simple and exciting: The ED of tomorrow won't look like the ED of today. The old processes won't serve us in the future, and the best practices will come from front-line workers thinking outside the box. What exciting changes might be ahead for our specialty in terms of ED operation? As you look at your ED operations, consider these innovations to help your “wait” loss program.

© 2008 Lippincott Williams & Wilkins, Inc.