Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals
Appendix C: Example Implementation Plan
Improvement Strategy Name: Mid-Track: The Solution to the ESI 3 Conundrum
Hospital: Good Samaritan Hospital Medical Center
Date: May 14, 2009
1. Goals and Strategies
In 2007, we identified that our left-without-being-seen (LWBS) rate of 3.5% was higher than acceptable. We implemented a plan to address this issue, and the LWBS rate dropped by nearly 45%. Though this represented a dramatic reduction, this rate eventually "plateaued" over the next 2 years at 2%.
When we analyzed these data, they clearly demonstrated that the Emergency Severity Index (ESI) 3 patients represented the most significant subgroup in the LWBS data. In fact, over 75% of all walk-outs were patients triaged to an ESI category 3, and 85% presented with one of six chief complaints. This patient population also had the longest wait time to be seen by a physician.
To expedite the care of the ESI 3 subpopulation of patients by reducing walk-out rates by 25% and an average time-to-provider to less than 60 minutes. We hope to achieve this within 3 months of initial implementation. We plan on implementing on 8/4/09. Therefore, we should reach this goal by the end of 10/09.
We will identify a subset of ESI 3 patients that will be affected by this strategy. This subset will include patients (1) whose chief complaint is any of the following: abdominal pain, vaginal bleeding, pregnancy complication, vomiting, flank pain, or headache; (2) those who meet predefined criteria; and (3) those who arrive to the emergency department (ED) Monday through Friday between 4 p.m. and 11 p.m.
We plan a two-step process for expediting care for ESI 3 patients. The first step is to add a physician to triage Monday through Friday between 4 p.m. and midnight (stretch will be extra hours and 7 days if possible). The subset of ESI 3 triaged patients will be referred directly to the physician in triage who will begin the evaluation of the patient and order appropriate tests. The second step is to utilize the ambulatory surgery unit (ASU) (which is one floor above the ED) as the ESI 3 patient district (mid-track). Here a nonphysician provider (NPP) will receive the patients and coordinate their care with the physician in triage.
To implement this strategy, we first had to identify an area of the ED that we could assign as the mid-track. We attempted to do this within the ED by reassigning one of the four geographic districts. However, the other districts were quickly overwhelmed with ESI level 1 and level 2 patients, and a disproportionate amount of acuity was being handled by the remaining three districts. This resulted in a number of complaints from the staff, and we terminated the pilot after the initial 1-month period. However, we needed to identify another space to house mid-track.
The ASU is directly above the ED, proximate to the ED staff and our radiology services. This area has operations between 6 a.m. and 6 p.m., with a significant decrease in census at 4 p.m. We approached administration, and approval was obtained to use this area after 4 p.m., with certain caveats:
We also had to identify a location within triage that the physician could occupy. We have five triage bays, and one is currently used for performing EKGs. This bay will be used for the physician. It contains a computer for documentation and an exam table/stretcher for evaluations. The physician in triage would only see a patient after the triage nurse assessed the patient and determined that the patient qualified for care under this new protocol. The physician would have the right to reassign the patient to the main ED if he or she felt that the severity of illness warranted it.
Conceptually, we realized that adding more space would not necessarily address the core problem: inpatients occupying ED beds and increasing the throughput times for all ED patients. However, given our options, this approach seemed to allow us to address the issue with expediency, while simultaneously developing programs to address the inpatient aspect of the throughput issue.
|Project Team Members|
|Name||Department||Role on Team|
|A. Sharma||Emergency||Project Director|
|S. Dries||Administration||Senior Leader|
|D. Alese||Administration||Senior Leader|
|T. Nolan||Administration||Nursing Leadership|
|J. Margulies||Emergency||Senior ED Physician|
|C. Butler||Emergency||Nurse Manager|
|C. Cicote||IT||System Analyst|
|K. Lock||Administration||Quality Manager|
|G. Leonte||Inpatient Units||Hospitalist|
Barriers to Successful Implementation (actual or potential)
|Activity (e.g., data collection, staff training, development of new forms, purchases)||Who is responsible?||Due Date|
|Obtain access and approval to use ASU for the ESI 3 patient district||A. Sharma||3/1/09|
|Hire additional physician, nurse practitioner, and support staff||A. Sharma||4/1/09|
|Purchase necessary equipment||A. Sharma||6/1/09|
|Arrange for housekeeping to clean the new district after midnight||A. Sharma||6/1/09|
|Arrange for security to be stationed in the new district during its open hours||A. Sharma||6/1/09|
|Create policies and procedures for (1) physician triage and (2) the new district||A. Sharma||6/1/09|
|Identify nursing staff and clinical staff to supervise patients in the new district||A. Sharma, C. Butler||6/1/09|
|Establish best-practice protocols for chief complaints||A. Sharma||6/1/09|
|Coordinate and orient nursing staff, techs, and support staff||C. Butler||6/1/09|
|Orient physicians and nurse practitioners||A. Sharma||7/1/09|
|Who needs to know about the strategy?||What information do they need?||When do they need the info?||Who will provide the info?|
|Administration||Implementation plan, policies, procedures, timelines||A. Sharma|
|ED Physicians||Implementation plan, policies, procedures, timelines, expectations||A. Sharma|
|Medical Staff||Implementation plan, policies, procedures, timelines, expectations||A. Sharma|
|ED Nursing Staff||Implementation plan, policies, procedures, timelines, expectations||C. Butler|
|Support Staff||Implementation plan, policies, procedures, timelines, expectations||C. Butler|
3. Estimated Time and Expenses
|Estimated Number of Hours for Implementation|
|Role||Name||Number of hours
|Number of weeks||Total number
|ED Chair and Physicians||35|
|Resources Needed for Implementation|
|Construction project for physician triage station||$8,000|
|Physician and lab tech||$300,000|
|Name||Issue for Approval||Date Approval Requested||Date Approval Obtained|
|Administration||To use the ASU as an ESI 3 district||2/11/09||2/11/09|
|ASU||To use the ASU as an ESI 3 district||2/11/09||2/11/09|
|Infection Control||To use the ASU as an ESI 3 district||2/11/09||2/11/09|
4. Performance Measures
|Performance Measures (check all that apply)|
|ED Arrival to ED Departure – Admitted Patients|
|ED Arrival to ED Departure – Discharged Patients|
|Admit Decision Time to ED Departure|
|Left Without Being Seen|
|ED Arrival to Bed|
|ED Arrival to Physician|
Page originally created September 2012