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

Solution:

  • 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

Results:

  • 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

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Figure 2. Emergency Department Daily Visits vs. Percent LWBS

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