Keith Hemmert, MD, discusses where to send a patient post-triage with Sinead Donnelly, MSN.

HUP CEO Regina Cunningham, PhD, RN, sees the opening of the Pavilion as a “great opportunity to think differently about how we deliver care, to not stay wedded to how things are always done but rather to drive positive changes.”

Transforming care in the ED in HUP West is already making these positive changes, with a new patient flow model that has not only improved emergency care in this ED but will easily translate into better efficiency when the ED moves across the street. Robin Wood, PhD, RN, ED nurse manager, said that the ED in the Pavilion was specifically designed with this type of flow model in mind. “We wanted to get staff used to the process here and will fine tune it when we move to the Pavilion.”

Two important changes have contributed to the improvement: a physician-in-triage system and implementing a vertical care model. The first changes prioritizes getting ED patients to see a physician within 30 minutes of arrival. In the former care model, patients underwent a nurse triage and then waited for an available exam room, where they were seen by a physician. But, “studies show that the longer it takes to see a doctor, the more likely a patient will walk out,” said Keith Hemmert, MD, director of Operations for Emergency Medicine. “And a significant number of patients who walk out are actually quite sick, and need to see an ED doctor.”

HUP’s new physician-in-triage – which is done right after the patient is registered – allows the physician to “quickly assess and order tests and administer medication,” Hemmert said. While there might still be a wait, “that wait time is being used is more productively — while the patient is waiting, diagnostic tests such as labs and imaging are underway.” Less acutely ill patients then move into an exam room in a special “Forward Flow” area, which is a separate zone in the ED. If none of those seven beds are available, the patient is brought to the “launchpad” (a queuing area outside of the Forward Flow) until a bed becomes available in Forward Flow.

The physician-in-triage works hand in hand with a patient flow coordinator, a nurse who decides with the physician on where to send the patient post triage: to the forward flow area or to the main ED. “This is the ultimate disciplinary collaboration regarding patient flow. One wouldn’t work without the other,” Wood said. “The nurse is the ultimate air traffic controller in the ED, the linchpin of the new model.”

The Vertical Care model specifically addresses the issue of patients remaining in an exam room until the results of lab tests and imaging return, keeping an exam room occupied for hours. “Vertical Care” refers to the ability of a patient to wait safely and comfortably in a chair after they have seen the doctor while they await test results versus a sicker patient, who will require the exam room for the entire stay.

Hemmert said that partnering with different service lines – i.e., having subspecialists involved earlier in the care of their patients in the ED — has also improved the flow of patients. For example, “with both renal and transplant teams closely involved, renal transplant patients can expeditiously move through the ED and receive much of their care in the ED Observation Unit.”

These changes “have enabled us to get more people through the system with less of a footprint and make more efficient use of limited resources,” Hemmert said. Indeed, since all initiating these changes this past spring, the percentage of HUP’s “walkaways” (patients who don’t complete treatment) has decreased from close to 10 down to around 3 percent. “And we want to be even lower,” Hemmert said. “It’s a matter of getting the right patients in the right place.”


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