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Split ED Flow, Watch Your Bottom Line Grow

Karen Minich-Pourshadi, for HealthLeaders Media, April 2, 2012

How does it work? Say Patient X presents at the ED with belly pain she's had for three weeks. The first stop is a quick look, where a registered nurse assesses the patient's condition and assigns an Emergency Severity Index number to route the patient through the ED.

If the vital signs are stable (an ESI of 3–5) then the patient sees a physician and RN together for assessment and testing. Patients don't return to the waiting room to await test results; instead they go to a continuing care area so an RN can monitor their vital signs and reaction to medication. The patient receives a pamphlet explaining the process, and care providers must check off each step in the patient's pamphlet.

"The idea is the patients who are less sick move through the process quickly," Johnson-Kelley says. "These patients only use 12 of our beds in the ED. However, there are small wait areas for the other steps in the process."

Contrast the process for patients with an ESI of 1–2 (critical care). If Patient Y comes in with chest pains, he bypasses the intake process and an ER technician performs an EKG and works to differentiate the type of chest pain.

"The beauty of this is we decrease the risk for the acute care patient in getting them from lobby to bed," Johnson-Kelley says.

But even acute care patients don't "own" their beds, she explains. If the patient stabilizes, he is moved to continuing care so the bed can be used by the next acute care patient.

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3 comments on "Split ED Flow, Watch Your Bottom Line Grow"

dmmitchell (4/6/2012 at 3:38 PM)
People come to the ED because they have are distressed or diseased. The Latin root of the prefix means discomfort with...something that all of us who work in the arena need to remember. Having worked as a RN in EDs for the past 25 years, I have some insight into both the process of the ED and as a consumer of how it feels to be either the patient or the patient's loved one. All patients should be greeted promptly, their anxieties acknowledged, and be informed of what will happen and approximately how long things will take, barring the unforseen. Will we satisfy every need of every individual? Of course not, but a little kindness and anticipation of what the presenting people are going through goes a long way. It is often the most basic things that are forgotten and it is the many small things that satisfy patients.

Kahlan (4/4/2012 at 5:22 PM)
Ms. Minich, I agree completely with Josh. One of the reasons Emergency Departments get backed up is that the majority of kids we see do not need "emergency" care. Parents need to educate themselves better on what truly constitutes an emergency. A toddler with a 102º fever does not, especially if it has lasted less than 24 hours. A child who is vomiting for less than 24 hours does also not constitute an emergency. Yet every time a child with an ear infection, pink eye or some other minor condition is brought to the ED rather than their own primary care physician, it takes up bed space and time for the patients who really DO need to be seen quickly. There is a finite number of beds in every ED and a limited number of staff to attend to them. Perhaps you would serve your readers better by educating them on which provider to see rather than slamming the hospital who didn't get you in and out in your preferred time. An ED is not a McDonalds.

josh (4/2/2012 at 5:35 PM)
Ms. Minich, I'm sorry your son was ill recently. But you went to an ER for a kid with a fever. An ER is there for gun shots, car crashes, heart attacks, etc. I don't know how sick or well your child may have been. But did you reach out to all the other places that would have given you as good or better care and would have provided as good or better satisfaction? Did you call your pediatrician or family doctor for telephone advice first to see if any immediate medical attention was needed? Did you go to an urgent care center or walk-in rather than a hospital ER? Does your pediatrician/family doc have extended evening and weekend hours? All of these might have gotten you faster more personal service. You asked, "why didn't the first nurse give us the diagnosis?" Because nurses don't make or give diagnoses, doctors (or nurse practitioners) do. "Why did we have to wait so long before being seen?" Because there are other sick patients who need the attention of medical care more urgently. "Why did it take 90 more minutes before we were sent home?" Maybe because it takes time to see if nausea medicine works and whether more interventions would be needed. Odd conclusions you draw. When people come to my ER and are disappointed, they think poorly of the ER and of ER's in general. They don't think poorly of the entire hospital or the entire health organization that owns it.