New Emergency Department Intake System Creates Vital Changes

LEXINGTON, Ky. (Oct. 23, 2019) — Overcrowded emergency rooms are a problem plaguing hospitals nationwide.

In a high-stress, high-stakes environment where every second counts, intervention is needed to reduce wait times and improve patient safety. UK HealthCare is taking the lead nationally to effect change.

According to the Centers for Disease Control and Prevention, nearly 146 million Americans visited an emergency room in 2016. A third of them spent between two and four hours in the emergency department (ED). In some cases, patients give up and leave before seeing a doctor.

“’Emergency’ and ‘wait’ are two words that cannot go together,” said Dr. J. Daniel Moore, an associate professor in the Department of Emergency Medicine at the University of Kentucky. “We should not be bringing patients back who are even more sick than they were when they walked through the doors just because they had to sit and wait for an exorbitant amount of time.”

Moore is part of a team at UK HealthCare that has developed a new way to route patients through the system efficiently, implementing a mixture of novel and evidence-based solutions that other institutions have successfully deployed. It has nearly eliminated the number of patients who leave the ED without being seen and is drastically improving patient access to the care they need.

Designing wait out of the system

If you walk into the waiting room of the UK Chandler ED today, it’s rare to see more than half a dozen people waiting for care. A few short years ago, the place looked like a busy bus terminal with dozens of crowded people waiting to see a doctor.

The UK HealthCare adult and pediatric ED’s at UK Chandler Hospital have about 90,000 emergency department visits each year with an average of 250 patients every day. Between Chandler and UK Good Samaritan Hospital, UK HealthCare has the busiest ED in the state and among the top 25% in the country.

Moore recognized the need for change and worked to implement a redesign of front-end processes, using the department’s own data.

“We were able to predict exactly how many patients per hour were arriving and exactly what resources were needed to match that demand,” he said.

It didn’t take long to see improvements: from the moment a patient walks through the door these days, it takes about 27 minutes for them to see a doctor at UK Chandler Hospital. Before the new intake system, the average wait time was more than twice that and even worse during the evening, which is the busiest time of day for emergency departments.

“Since implementing this system we are more efficiently able to identify patients who are safe to go home, creating five million additional minutes per year of functional capacity to treat the sickest patients. That’s huge,” Moore said.

The UK Chandler ED is the one of the first academic hospitals in the country to achieve this level of success.

Moore is seeing an improvement in patient safety as well. Some patients without a family doctor use the ED for all of their medical needs, which slows the intake system down. Combined with longer lobby wait times, this meant some very sick patients were lost in the crowd and couldn’t get the help they needed fast enough. Today, every patient who walks through the door is seen by a nurse during registration and an attending physician within minutes. If they need immediate care, it’s recognized and they get it.

“We’re so much more efficient now that we don’t have patients just sitting out there for long periods,” said Patti Howard, enterprise director of Emergency Services for UK HealthCare. “In the past, they registered, but had to wait in line with everyone else.”

Howard has seen the most dramatic change in the number of patients who leave the ED without being seen.

“A lot of people think that those are the people who don’t need to be here to start with,” she said. “Unfortunately, many of the people who leave are the very ones who need to be seen.”

The national benchmark for the percentage of patients who leave before seeing a doctor is 2%, although Howard said the norm is about 3%. UK was running in the 3.5% to 4% range before establishing the new patient intake system. Now, Howard said, the hospital is a national best performer with less than 0.3% of patients leaving the emergency department without being seen. 

"And more importantly, we've been able to sustain this gain for two years, despite increasing volumes and worsening hospital crowding," said Howard.

How it works: A novel approach

Moore’s approach is called a Physician Intake Pod with Vertical Split Flow (PIP-VSF). This system requires a front end team: a pivot nurse, an attending physician, a scribe, two triage nurses, two paramedics and a nursing care tech. There is also a “vertical treatment space” staffed with two advanced practice providers (APPs), two nurses and a nursing care tech. 

You’re put into the system soon after you walk into the ED. The first person you’ll interact with is a pivot nurse, like Eryn Van Meter.

“We used to be behind a door and you never knew what you were getting until you grabbed a chart,” Van Meter said.  “Now, you actually see the people as they walk in. You don’t have to wait for them to register. If you see somebody sick, you immediately know it."

That helps get the patient back to a doctor faster. The pivot nurse role requires quick thinking and crisp clinical judgment. Van Meter enjoys the challenge.

“I think everyone in the ED is an adrenaline junkie, whether we admit to it or not. You have to be in this environment. You never know what you’re going to walk into,” she said.

Patients brought in by ambulance get their vitals checked and are assigned an acuity level from 1 to 5. The most critical patients are sent straight back for treatment. Patients who are less critical are entered into PIP-VSF.

There are two triage rooms in the UK Chandler ED. A registered nurse and doctor assess the patient together before the doctor decides if the patient needs to lie down (horizontal), can stay seated (vertical), or can be discharged. The nurse simultaneously places any orders for bloodwork, radiology and therapeutic interventions while the scribe generates a chart. As a result, a physician can screen up to 10 patients per hour, which is five times greater than the normal productivity of an emergency physician. 

“This model has shown to be effective at large primary academic centers dealing with a near constant demand for capacity,” Moore said.

Dr. Roger Humphries, chair of the UK Department of Emergency Medicine, knows that there's still more to do. Like other academic medical centers around the U.S., there are still more patients than beds, but that’s a consistent problem nationwide.

By implementing this system, the UK Chandler ED is becoming part of the solution. Because this system was so effective, what used to be the waiting room has now been partially re-designed to add more vertical treatment space.

“Overall, the difference this process has made in our ED over two years is unprecedented,” said Humphries. “We are excited to share our research, to share proven results with other hospitals and be a leader for positive change.”