According to the CDC, nearly 130 million patients visit emergency rooms in the United States per year. And if you’re one of those 130 million, you might have noticed there’s a lot of waiting around. Patients all over the country lament long wait times, and unfortunately, some even leave before seeing a provider.
What’s more, due to shifting demographics and resources, hospitals are declining in number, but visits are increasing, which only exacerbates crowding issues and increases wait times. In 2018, 56 percent of patients nationwide waited nearly an hour to see a provider in the emergency department (ED), and 3.56 percent walked away without even having seen a doctor or receiving treatment. Hospital data also reveals that patients who walked away are often experiencing high-acuity medical events, like chest pain.
With this increasing volume of patients and decreasing space, how can hospitals see patients quickly and still provide exceptional care? The Hospital of the University of Pennsylvania (HUP) has reimagined the ED, making the experience more efficient and seamless, guaranteeing that patients are not only treated quickly, but that they receive the highest level of care possible. This fall, HUP will further optimize their ED with the opening of a state-of-the-art two-floor ED in the Pavilion, which was designed specifically to incorporate the system already in place at HUP, and will have the capacity to deliver quicker, more efficient patient care.
Based on AAAEM/AACEM Benchmark surveys conducted by the Society of Academic Emergency Medicine (SAEM), the benchmarks for ED care are to have patients see a physician in less than 30 minutes from when they enter the hospital, and to keep as many people from walking away without being seen as possible. Further, experts advise that the average length of an ED visit total should be less than four hours for patients who are discharged. The team at HUP’s goal is to continually exceed these standards.
Led by Benjamin Sun, MD, MPP, chair of Emergency Medicine in the Perelman School of Medicine at the University of Pennsylvania, and Keith Hemmert, MD, an assistant professor of Clinical Emergency Medicine at Penn, Jeff Moon, MD, MPH, director of Emergency Medicine Clinical Informatics, Robin Wood, PhD, RN, a clinical director of Nursing, and Amy Lockwood, MSN, CRNP, Manager of Advanced Practice Providers, HUP implemented a major adjustment made to ED patient flow model to improve both patient outcomes and experience in advance of the new ED opening up across the street at the Pavilion, which will open doors later this year. (Penn Presbyterian Medical Center has since implemented similar changes, too.)
In traditional ED settings, a patient arrives at the ED, checks in and is assessed by a nurse, and then will wait to see a provider. Then, a provider gives the patient a quick assessment, and ranks them on their need based on their prognosis — triaging care as appropriate. For example, while care may be escalated quickly for something like cardiac arrest, those who are experiencing a less critical event, like abdominal pain, will wait for blood and urine tests. After they are evaluated, patients may occupy a bed for the remainder of their visit, regardless of how critical their need is. In the standard model, patients who are simply waiting for x-ray results or for a splint for a broken bone could occupy a bed in the ED for an extended time, while patients with more life-threatening cases may be forced to wait.
At HUP, the ED has been operating with a different model, called a “vertical care model” since 2019. In this new model, rather than remaining in the waiting room to be triaged by a nurse or physician, all ED patients see a physician right away. In this quick encounter, usually lasting anywhere from three to eight minutes, a doctor will evaluate the patient; place orders for lab work, imaging, or medications; and decide whether that patient will need to occupy a full room and bed for further treatment and observation. Patients who don’t require a bed for their entire visit are fast-tracked to a different area to wait for test or imaging results. Under this system, beds and rooms are available to the sickest patients who need them the most, and every patient is seen and has their needs addressed quickly and efficiently.
For the past two years, HUP has utilized the vertical care model in its ED to remarkable results, significantly reducing the number of walk-aways, door-to-provider time, and overall time to discharge. Under the new system, HUP is comfortably below nationwide benchmarks.
“The speed with which patients see a provider, receive treatment, and are discharged are all important metrics,” Sun said. “But we also prioritize providing the highest level of attention and care to every case, and this new model makes that possible.”
The improved ED at the Pavilion will build upon this success and implement adjustments that address some of the less-efficient aspects of the existing ED facilities at HUP. For example, in the new triage area, providers will come to the patient in the triage room rather than have the patient move from station to station for different steps during their initial evaluation, such as from the initial intake consultation to getting their blood drawn, and so on. This system helps to reduce bottlenecking events and increases the speed with which a patient receives treatment.
The space in which patients will await results in the Pavilion was designed with privacy and comfort in mind, with cubicle-style dividers and comfy reclining chairs. The top 12 inches of the dividers are glass to allow for natural light, and each space has room for one visitor. Two nurses will staff this area to address any patient concerns.
“While these patients with less severe cases don’t need access to a bed, we still want them to be comfortable and feel safe while they await next steps,” Hemmert said. “No visit to the ED is ever a pleasant experience, but by streamlining the patient experience, we alleviate as much stress from patients as possible.”