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Introduction of a Horizontal and Vertical Split Flow Model of Emergency Department Patients as a Response to Overcrowding

Published:November 20, 2017DOI:https://doi.org/10.1016/j.jen.2017.10.017

      Abstract

      Introduction

      ED overcrowding is an issue that is affecting every emergency department and every hospital. The inability to maintain patient flow into and out of the emergency department paralyzes the ability to provide effective and timely patient care. Many solutions have been proposed on how to mitigate the effects of ED overcrowding. Solutions involve either hospital-wide initiatives or ED-based solutions. In this article, the authors seek to describe and provide metrics for a patient flow methodology that targets ESI 3 patients in a vertical flow model.

      Methods

      In the Stanford Emergency Department, a vertical flow model was created from existing ED space by removing fold-down horizontal stretchers and replacing them with multiple chairs that allowed for assessment and medical management in an upright sitting position. The model was launched and sustained through frequent interdisciplinary huddles, detailed inclusion and exclusion criteria, scripted text on how to promote the flow model to patients, and close analytics of metrics. Metrics for success included patient length of stay (LOS) for those triaged to the vertical flow area compared with ESI 3 patients triaged to the traditional emergency department as a comparison group. The secondary outcome is the total number of patients seen in the vertical flow area. This was a 6-month—September 2014, to February 2015—retrospective pre- and postintervention study that examined LOS as a marker for effective launch and implementation of a vertical patient workflow model.

      Results

      The patients triaged to the vertical flow area in the study period tended to be younger than in the control period (43 years versus 52 years, P = 0.00). There was a significant decrease in our primary end point: the total LOS for ESI 3 patients triaged to the vertical flow area (270 minutes versus 384 minutes, P = 0.00).

      Conclusion

      Implementation of a vertical patient flow strategy can decrease LOS for the vertical ESI 3 patients based upon the inclusion and exclusion criteria. Furthermore, this is accomplished with minimal financial investment within the physical constraints of an existing emergency department.
      Contribution to Emergency Nursing Practice
      • Low cost solution to overcrowding
      • Decreasing length of stay for emergency severity index (ESI) 3 patients
      • Ability to treat more patients in the same space
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      Biography

      Gregory Wallingford Jr is Emergency Medicine Resident, Stanford University Department of Emergency Medicine, Palo Alto, CA.

      Biography

      Nikita Joshi is Clinical Instructor, Stanford University of Emergency Medicine, Palo Alto, CA.

      Biography

      Patrice Callagy is Director of Emergency Services, Stanford University Department of Emergency Medicine, Palo Alto, CA.

      Biography

      Jamie Stone is Assistant Patient Care Manager, Stanford University Department of Emergency Medicine, Palo Alto, CA.

      Biography

      Ian Brown is Clinical Assistant Professor, Stanford University Department of Emergency Medicine, Palo Alto, CA.

      Biography

      Sam Shen is Medical Director, Emergency Medicine and Clinical Associate Professor, Stanford University Department of Emergency Medicine, Palo Alto, CA.