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Optimizing Front End Flow
Jody Crane, MD, MBA, FACEP
Chief Medical Officer, TeamHealth
EDDA, 2019
Outline
Key ConceptsDoor to In-Process
Vertical vs. Horizontal
Patient Streaming
Operational ModelsTriage Protocols
Direct Bedding
Super Track
PIT
Intake Systems
© 2019, Crane
Outline
Key ConceptsDoor to In-Process
Vertical vs. Horizontal
Patient Streaming
Operational ModelsTriage Protocols
Direct Bedding
Super Track
PIT
Intake Systems
© 2019, Crane
It’s Really Very Straightforward….
© 2019, Crane
What do Patients Really Want???
Get in (see the doctor ASAP)
Get treated (start getting better)
Get out (home or upstairs)
The more efficiently you can do these
things, the happier your patients will be
Focus on creating value, eliminating waste
and uncouple your key servers
© 2019, Crane
Get InGet BetterGet Out
Patient
Triage
Waiting
for Test
Results
Room
Assignment
MD or
Midlevel
Encounter
Data
Collection
Data
Assessment
Patient
Initial
Treatment
Patient
Disposition
Definitive
Patient
Treatment
Ideal V
alu
e A
dd
ed
Patient Process
© 2019, Crane
Patient
Triage
Waiting
Room
Assignment
MD or
Midlevel
Encounter
Data
Collection
Data
Assessment
Patient
Treatment
Patient
Disposition
Tra
dit
ion
al
No
n V
alu
e A
dd
ed
NVA,
in-process
waiting
NVA,
pre-process
waiting
Outline
Key ConceptsDoor to In-Process
Vertical vs. Horizontal
Patient Streaming
Operational ModelsTriage Protocols
Direct Bedding
Super Track
PIT
Intake Systems
© 2019, Crane
Get Patients “In-Process” ASAP
1. DIP – “Door to In-Process” The most important interval!
2. Executing on the physician order is key!
3. Must have reliable ability to draw blood, transport patients to and from diagnostics, and give meds without the nurse running all over the ED. POC testing is bonus.
4. System should be designed to optimize physician and nurse value
5. Physicians should order only necessary diagnostics and treatments (no or few IVs, for example), in order to maximize nurse and tech efficiency
6. No test should be ordered that won’t change your management (i.e. lumbar films)
© 2019, Crane
Outline
Key ConceptsDoor to In-Process
Vertical vs. Horizontal
Patient Streaming
Operational ModelsTriage Protocols
Direct Bedding
Super Track
PIT
Intake Systems
© 2019, Crane
“Horizontal” vs. “Vertical” Patients
Horizontal
Sick
Older
Stretcher bound
Likely Admission
Variable Workup
Treatment Limited
Vertical
Well
Younger
Ambulatory
Likely Discharged
“Algorithmic”
Diagnostic limited
© 2019, Crane
Why do Patients Need Beds?
Reasons vertical patients need beds:
Evaluation
Private consultation
Treatment
Monitoring
All other bed time is NVA
This allows you to offload your bed bottleneck
© 2019, Crane
Results Waiting
Internal
Patients don’t feel
they’re sent to WR
WR is empty
Closer supervision
Less elopement
More comfortable
Less space
External
Patients may feel
going back to WR
WR looks busy
Less supervision
More elopement
Less comfortable
More space
© 2019, Crane
Ochsner Medical Center – Q Track
© 2019, Crane
© 2019, Crane
© 2019, Crane
Outline
Key ConceptsDoor to In-Process
Vertical vs. Horizontal
Patient Streaming
Operational ModelsTriage Protocols
Direct Bedding
Super Track
PIT
Intake Systems
© 2019, Crane
Pivot RN1. Initially sorts patients
2. Identify sick patients
3. Patient placement
Reception1. Tech – Patient Sign-in
2. Reg Clerk – Quick reg
3. Pivot RN
© 2019, Crane
There are Really Only 3 Types
of ED Patients…
SickEasy Complicated
Simple Complicated ComplexA. Gawande, Checklist Manfesto
© 2019, Crane
2'-8
7/8
"
6'-5 5/8"
2'-8
7/8
"
6'-5 5/8"
2'-8
7/8
"
6'-5 5/8"
2'-8
7/8
"6'-5 5/8"
2'-8
7/8
"
6'-5 5/8"
2'-8
7/8
"
6'-5 5/8"
6'-3/8"
13
'-3
"
42 43 44 4645
49
48
47
23
24
2526
OR 1
Lab -
Phlebotomy
50
OR 2OR 3
OR 4
TR 9
TR 8
TR 7
TR 5
TR 6
16 15 14
13
12
10
11
18
19
20
21
22
28
29
31 30 17
27
32
33
39
38
37
36
35
34
41
40Peds
WR
Rainbow
Room
(Internal
Waiting)
Treat
ment
Intake
Team 1
Team 2
Rad
Room
SuperMini
Triage
TrackDischarge
Intake
Treat
ment
Treatment
Treat
ment
15-20%
Super Track
ESI 4-5
20-30%
Main ED
ESI 1-3
50-60%
Intake/PODs
ESI 3
Emergency
Streaming
Pivot RN
Pivot RNInitially sorts ST patients
Identify Level 1,2 patients
Patient placement
© 2019, Crane
Demand - Arrival Acuity by HOD
© 2019, Crane
Low, Mid, High Acuity Arrivals
© 2019, Crane
Low Acuity Arrivals = ESI 4,5
© 2019, Crane
Intake Arrivals – ESI 4, 5, 33% ESI 3
4 Vertical,
4.5 Horizontal
© 2019, Crane
Outline
Key ConceptsDoor to In-Process
Vertical vs. Horizontal
Patient Streaming
Operational ModelsTriage Protocols
Direct Bedding
Super Track
PIT
Intake Systems
© 2019, Crane
© 2019, Crane
Outline
Key ConceptsDoor to In-Process
Vertical vs. Horizontal
Patient Streaming
Operational ModelsTriage Protocols
Direct Bedding
Super Track
PIT
Intake Systems
© 2019, Crane
Evaluation Streaming Pathways (ESP) for KPMAS
Leve
l 3 –
U
rgen
t C
are
Tria
geLe
vel 2
–
Inta
keLe
vel 1
–
Mai
n C
DU
Tria
ge A
sses
smen
tN
ame,
Age
, CC
, VS
Acu
ity
Ass
ign
men
t*M
ove
to
Mo
st A
pp
rop
riat
e A
rea
as A
cuit
y D
icta
tes
Sick/Not Sick?
Round Robin Assignment, Direct
Bedding in Main CDU1pt/hr
Sick
Easy/Not Easy?
Complicated
Round Robin Assignment, Intake
2pts/hr
PIT, 3pts/hr
EasyNot Sick
· AMS· Severe Pain Distress· High-risk · Abnormal Vitals
Patients with variable work-ups that would benefit from initial physician screening
· Basic Physician and Nurse procedure(s)
· 1 lab and/or rad· PO or IM meds only
Chief Complaint CBC CHEM7 TROP HCG (♀
only)
Bedside
Glucose
UA and
CX
EKG Chest
XR
Peak
flow
Blood
Cultures
Pulse
Ox
Treatments
To Holding immediately if unstable
Abd Pain NPO: If pain upper abd add Serum Amylase, Lipase, LFT.
Pregnancy: FHTs for gest>12wks. Progressive HCG.
Asthma-Adult Breath Sounds-SaO2<92% initiate 2L PRN If no
contraindications: Albuterol 1 unit dose neb
Asthma-Peds Breath Sounds-SaO2<92% initiate 2L PRN If no
contraindications: Albuterol 1 unit dose neb
Back Pain-No Injury
Bone Injury XR of affected area. Urine HCG not needed if shielding.
Chest Pain >40 yo Start EKG w/in 10 min. Place IV Saline Lock.
Chest pain <40 yo Start EKG w/in 10 min.
Confusion
Diarrhea Orthostatic Vitals; If orthostatic, place IV Saline Lock
Dizziness Orthostatic Vitals; If orthostatic, place IV Saline Lock
Eye ComplaintsVisual acuity. Immediate eye flush for chemical exposure;
Other than conjunctivitis, contact MD immediately
Flank Pain Place IV Saline Lock.
GI Bleed Orthostatic Vitals/PT/PTT/INR studies if on anticoag meds.
If orthostatic, place IV Saline Lock
Mental Health/OD Hepatic Panel, Urine Toxicology, BAL, Urine Beta, TSH, Safety
check
Palpitations Draw TSH
Pediatric Fever Tylenol 15 mg/kg PO OR if >6 mos Ibuprofen 10 mg/kg;
Collect but do not send UA
Shortness of Breath Initiate O2 at 2LPM for sat<92%-Take to holding, consult
MD for additional lab work
Sickle Cell Crisis Reticulocyte Count (send out test)-Blood culture if
fever>101.5; Place IV Saline Lock
Sore Throat Rapid Strep
UTI Symptoms Urine GC/Chlamydia for males with dysuria and penile
discharge
Vaginal Bleeding Pregnancy: Progressive Serum Beta HCG if positive. FHT's
if>12 weeks
Vaginal Discharge
Vomiting
Orthostatic/Zofran ODT 4 mg PO/NPO; if orthostatic place
IV Saline lock. If associated with abd pain, refer to abd pain
triage
Abnormal Vitals?
If expected Door to Doc time exceeds 1 hour, then implement
Triage Protocols
> 1h Wait?
Basic: Foley in/out or placement PO or IM medication Blood draw Advanced: IV Placement and/or IV MedicationConscious Sedation Critical Care Nursing
Basic: Laceration Repair Abscess I&D Wound Care Advanced: Lumbar Puncture Fracture or Dislocation Reduction Conscious Sedation Critical Care Procedures
Ph
ysic
ian
P
roce
du
res
Nu
rsin
gP
roce
du
res
Tria
ge A
sses
smen
tN
ame,
Age
, CC
,VS
Acu
ity
Ass
ign
men
tB
ed P
lace
men
t W
hen
Ava
ilab
leAnticipated Door to Bed Delays
Abscess Breast Complaint Eye Complaint MVA - musculoskeletal Urinary Complaint
Allergic Reaction - skin Cellulitis - focal Facial Complaint Neck Complaint Wound check
Animal Bite Chest Pain <30yo Flu-like symptoms <50yo Pregnancy Check
Back Pain <50yo Cough/Congestion <50yo Foreign Body Puncture
Ambulatory Dental Complaint Head Injury - minor Rabies
Minor injury Ear Complaint Insect Bite Rash/Skin Problem
No x-rays Extremity Pain - no deformity Laceration - minor Sore Throat
No IV meds Extremity Swelling - poss DVT Med Refill Superficial Bleeding
Abdominal Complaint Dizziness Nosebleed - mild or stopped
Allergic Reaction - SystemicFever >3mo, <60yo Pelvic Pain
Asthma Flank Pain >50yo Rectal Complaint
Back Pain >50yo Flu-like Symptoms >50yo SOB - Infection, <50yo
Chest Pain >30yo Groin Complaint Vaginal Complaint
Cough/Congestion >50yo Headache <50yo w/history Visual Complaint
Diarrhea Nausea, Vomiting Wound - post operative or serious
AMS DKA - suspected Flank Pain >40yo Hypertension - diast >120
Back Pain - abnl neuro or bp Fall > 10ft Flu-like symptoms - hypoxia SOB >50yo
Chest Pain c/w ACS or PE Fever GI Bleed Syncope
CVA <3mo, >60yo Headache >50yo Gen Weakness >50yo
Dizziness Immunocompromised Hypotension
Sepsis - possible
Pulse Resp SBP Temp Sat
<3mo >180 >50 <60 >100.4
3m-3y >160 >40 <80
3y-8y >140 >30
>8yo >100 >20
>102.2<90
<92%
Triage
Protocols
© 2019, Crane
Triage Protocols
Good if all MDs are in agreement, RNs have reliable
assessments and use them.
If not all tests ordered, no time saved.
If too many tests ordered, waste and higher utilization
of ancillaries.
Physician may have been able to discharge patient
without labs, but now they are pending.
Should only be implemented when there are
temporary waiting periods, >60 min door to doc.
© 2019, Crane
Outline
Key ConceptsDoor to In-Process
Vertical vs. Horizontal
Patient Streaming
Operational ModelsTriage Protocols
Direct Bedding
Super Track
PIT
Intake Systems
© 2019, Crane
Direct Bedding
© 2019, Crane
Direct Pullback/Immediate Bedding
Pros
Gets patients in front of
treating doctor
Less potential for triage
congestion
Eliminates triage waste
Cons
Often nursing conflict
Potential for increased
risk if treating nurse is
tied up with sick patient
If beds are a constraint
will reliably fail daily
If other resource
constraints, census can
escalate
© 2019, Crane
Innovative Operational Models
Most efficient EDs Allow for connection of physicians and or midlevels at the front end and take great care to limit other variables such as bed or nursing availability
Low AcuityFast Track
Super Track – MWHC
Provider in TriagePIT – Sacramento
RME – CEP
Conveyance - HCA
Provider Directed Queuing – Chris Deflitch, Hershey, Penn State
Intake Systems/Split FlowSplit Flow – Cochran, Roche, Banner Health
RATED/Super Track – MWHC
qTrack – Joe Guarisco, Oschner Health
© 2019, Crane
Outline
Key ConceptsDoor to In-Process
Vertical vs. Horizontal
Patient Streaming
Operational ModelsTriage Protocols
Direct Bedding
Super Track
PIT
Intake Systems
© 2019, Crane
© 2019, Crane© 2019, Crane
© 2019, Crane
“Super Track”
Fast Track located in or near triage for the purpose of promptly treating patients who require very low resource utilization
Treatment
Room 1
Treatment
Room 2
Procedure
ChairResults
Waiting
1 Doc/MLP
1 RN/LPN
1 Tech
Entrance/Exit
© 2019, Crane
© 2019, Crane
Outline
Key ConceptsDoor to In-Process
Vertical vs. Horizontal
Patient Streaming
Operational ModelsTriage Protocols
Direct Bedding
Super Track
PIT
Intake Systems
© 2019, Crane
Rapid Medical Evaluation
Physician in Triage
Discharging all lower
acuity patients
Getting things started
on all mid and high
acuity patients that
may experience bed
delays
© 2019, Crane© 2019, Crane
“NP Triage”
Triage area staffed only by Nurse Practitioners who treat and release low acuity patients and streaming/triaging higher acuity patients to other areas in the ED
Nurse Practitioners
Results
Waiting
© 2019, Crane
Outline
Key ConceptsDoor to In-Process
Vertical vs. Horizontal
Patient Streaming
Operational ModelsTriage Protocols
Direct Bedding
Super Track
PIT
Intake Systems
© 2019, Crane
Intake Systems
Team of providers utilizing an “intake team” mentality for promptly assessing, treating, and discharging level 3 patients
2 Providers (Doc/MLP),
2 RN/LPN,1 Paramedic
2 Scribes, 1PSR/HUC
Quick Look
Quick Reg
Quick
Triage
Treatment
Area
5 Rooms
Results
Waiting© 2019, Crane
What’s Next? Self Checkout?
© 2019, Crane
Triage Direct Admit?
© 2019, Crane
Conclusions
Key concepts for improving the front end include
the “DIP”, Streaming, and Horizontal vs Vertical
Patients.
There are many strategies to facilitate the front
end including direct bedding, Super Track, PIT,
and Intake Teams.
The different models described have specific
settings where they will be most effective based
on volume and acuity.
© 2019, Crane
