Many people have written about the segmentation of patient populations in the emergency department, based on acuity. Let’s take a look at it a little more closely in today’s installment of the patient flow series.
Patient segmentation is the process of dividing patients (based on acuity in our case) and processing them through an emergency department visit differently based on the category they fall into. The most basic of these processes is the ED fast track. Typically, low acuity patients are selected to go here and have devoted staff and resources to expedite their care and discharge. However, many of today’s emergency departments find themselves overwhelmed with higher acuity patients and this type of segmentation has little impact on that population. A fast track may reduce length of stay for low acuity patients and decompress a waiting room, but higher acuity patients will still wait. Is there a secondary level of segmentation?
The next population that can be pulled away are the ESI 3’s or Emergency Severity Index acuity level 3 patients. These patients are a heterogeneous population encompassing those that can be treated in chairs while awaiting diagnostics, the so-called “vertical” patients, and those that will require a bed or stretcher. Since needs are variable, it can be difficult to structure an optimal flow for these patients. However, one can take advantage of the differences. An ideal area for these patients can be structured as follows:
- A dedicated area with patient care rooms AND a large communal area with chairs and curtains. In this manner, those that require a bed are placed in one, and those that do not, are treated up right. One physician, along with an advanced practice provider if volume is high, should be dedicated to this area along with nursing. Focus is placed on rapidly providing the variable levels of treatment.
- An alternate model involves subdividing the ESI 3’s and treating those that do not require a bed in an area adjacent to the waiting room. Though this has met with some success, ESI 3’s will require the watchful eye of a physician and small triage areas with only an advanced practice provider should not be relied upon to take care of this population.
Would your ED benefit from a dedicated ESI 3 treatment area? The answer is in the numbers.
- What is your percentage of ESI 3 patients? If it is over 40% (and most are), the answer is yes. Why 40%? Most electronic systems are not capable of breaking down the ESI 3’s into the vertical (chair) and horizontal (bed) categories. If we assume the split is 50/50 (and that is only an assumption), then you have sufficient volume of vertical patients to dedicate space up front, or build out the mixed vertical/horizontal area instead.
- What is your length of stay for ESI 3 patients? If it is over 3 hours, the answer is yes. Dedicating space and resources for this population reduces their length of stay.
The last population are the high acuity patients, ESI 1s and 2s. These are usually already segmented in your ED, even if you don’t think of it in that manner. Take trauma for example. Most emergency departments have a trauma room. That is a form of segmentation. Most will have a resuscitation room, that is another form of segmentation. You may be working in an ED where the majority of your volume is composed of ESI 1 and 2 patients. This can occur when there is a near by urgent care center, and the hospital is a large tertiary referral center. In this instance, the traditional segmentation (fast track, level 3 area) is insufficient. You must understand that you are working with a resource intense population that is different from most departments in the country. However you still have options. Consider some of these:
- Staffing a dedicated hospitalist or admissions team in this area since all but few will be admitted.
- Adding a second CT scanner to the department and dedicating it to these patients as most will require imaging.
- Building a dedicated ED lab to process 90% of your lab needs without competition from inpatient resources.
- Double staffing ED physician coverage, or more depending on volume with expected hourly patient productivity around 1.5 pts/hr.
These are expensive additions. However, what these changes essentially accomplish is the creation of a virtual emergency department intensive care unit. The emergency department serves as a mirror of your hospital (The ED As A Mirror). This particular type of ED is usually attached to a large center with large ICU utilization, often from referrals. These patients can bring department flow to a halt if under-resourced since it is the natural reaction to place them in any open bed, even that bed was otherwise dedicated to lower acuity. Understanding the unique load they bring will go a long way in properly resourcing the department.
In these scenarios, patient segmentation is a dedication of resources to a particular acuity of patient. These examples need not be performed in isolation. Departments function very well with a fast track and a “mid-track” for ESI 3’s. The answer to your needs is in your acuity mix and hourly arrivals. Keep in mind, it is not wise to run these resources 24/7. Each solution is matched to the hourly arrivals to determine hours and days of the week. Also, it is important to remember that data should guide your selection of segmentation in your ED. As we see above, each of these has a very different effect on the patients waiting and must be selected for the appropriate setting.
Has your department had success in segmentation? or are you struggling with a specific population? Join the discussion at www.admin-em.com.