Emergency Department Setting:

  • Regional trauma center in large city
  • 80,000 annual ED visits
  • 45 ED beds

Key Concepts:

  • Move initial physician evaluation “forward”
  • Rapid initiation of diagnostics
  • Patients see physician earlier in visit
  • Create “virtual ED beds” with fast turn-over
  • Quick and simple disposition of very minor patients, reserve valuable bed space
  • Second initial assessment, early in visit, to back-up triage nurse and reduce triage error


  • Patient presents at front deskTwo nurses provide “quick look” triage
  • If a true emergent condition is identified, patient is immediately taken to appropriate treatment area (usually critical medicine/trauma)
  • Otherwise, clerk simultaneously takes minimal information to match medical record number or creates new number, and enters patient into tracking system
  • Patient is then fully assessed and triaged
  • Majority of patients then go to the virtual ED composed of two beds and staffed by an ED physician, NP or PA, and nurses
  • Level 3 patients typically have work started (i.e., lab, x-ray, CT) and are then sent to the main Emergency Department for further treatment and disposition
  • Level 4 & 5 patients may be quickly treated and discharged, or can go to designated area for minor procedures, etc.
  • Allows ED Physicians to pick up patients who are already in process and ready for further treatment and disposition
  • When the Emergency Department is at capacity, patients may return to waiting room until treatment space is available; however, work-up is in progress


  • Reduced number of patients who leave without being treated (LWBS) by more than 50%
  • No additional ED staff resources required – some of the work load starting diagnostic work-ups shifted to virtual ED, and staff shifted with that work load
  • Reduced triage error, especially under triage resulting in ill patients in waiting room
  • Reduced congestion in main Emergency Department, with minor patients never moving past Virtual ED
  • Extremely valuable during peak volumes and high occupancy
  • Physicians in virtual ED rotate shift equally with other ED docs and are paid an hourly rate

Figure 1. Emergency Department Length of Visit Input and Output


Figure 2. Emergency Department Daily Visits vs. Percent LWBS