The leadership team in the Tennity Emergency Department at Eisenhower Health in Rancho Mirage, California, was struggling with their operations. The Tennity ED was seeing more than 83,000 patients annually in its 55-bed emergency department. The Coachella Valley is a popular retirement/resort destination, and the patient makeup at Tennity is heavily geriatric (56 percent). The admission rate varies by season between 25 and 30 percent, and boarding was problematic during peak times. Eisenhower Health is home to a new emergency medicine residency, so the teaching mission is important and another factor in ED operational efficiency.
Explore This IssueACEP Now: Vol 40 – No 02 – February 2021
Prior to the COVID-19 pandemic, the department was struggling to see patients in a timely manner, with door-to-clinician times at 70 minutes and total walkaway rates (left before treatment complete, or LBTC) topping out at 9.2 percent. The ED and hospital leaders wanted to reengineer their emergency department to better meet the demands of the community, and they began working on that before the pandemic. Rather than stopping the redesign when the pandemic hit, they soldiered throughout the following six months to accomplish the task. Marty Massiello, chief operating officer, and Ann Mostofi, chief nursing officer, provided the ED leadership team with process-improvement professionals and the right resources to support the project. Everyone stepped up.
The leadership team—medical director Euthym Kontaxis, MD; department chairman and operations director David Romness, MD; ED nursing director Tasha Anderson, RN; assistant nursing director Joshua Hickman, RN; nurse practitioner Ervin Xhufka, RN; process-improvement lead Joseph Torres; and Epic data analyst Andres Beltran—brought together representatives from all stakeholder groups to redesign the emergency department. The team ambitiously developed a sophisticated flow model with complex patient streaming built upon a physician in triage (PIT) platform (see Figure 1). Because low-acuity volumes were dropping, the team found that populating a traditional fast track was hit-or-miss. The department decided on a rapid treatment unit (RTU) model, which is a flexible unit that merges fast track and “mid track” functions and responds to the Emergency Severity Index (ESI) distribution that presents to the emergency department on any given day.
Table 1: Tennity ED Metrics Before and After
|Before COVID||After COVID||After Improvement|
|Patients per day||229||153||179|
|Door to doctor (minutes)||70||86||14|
|Left before treatment complete||0.092||0.075||0.019|
|Left without being seen||0.024||0.064||0.007|
|Length of stay (minutes)||264||332||225|
The New Flow
All patients are seen by a rapid assessment nurse and a registration clerk, where a quick (less than three minute) intake process begins. Registration creates a patient identity, and the assessment nurse does a “quick-look ESI” with a chief complaint, allergies, and pulse oximetry readings. This is enough information for the first round of patient sorting. Patients needing immediate bedding are sent to the acute care areas. Patients who can remain vertical and are deemed nonacute pass through the PIT. The PIT experience is rapid: The physician does a quick, focused history and physical; places orders; and writes a very abbreviated note. The ED tech draws labs and/or obtains an ECG, and the patient is escorted to the area selected by the physician as the most appropriate zone.
PIT patient streaming is based on acuity as designated by ESI and anticipated length of stay, which the physician is best at determining. The entire PIT process takes less than six minutes per patient. Scripting and information cards are used to explain the new process to the patient. The patient may go to one of the following areas: fast track; mid track (both located in the RTU); acute care zones 1, 2, or 3; or a psychiatric bed. The icing on the cake for the whole flow model is the institution of flow nurses called “patient flow coordinators” who constantly monitor flow and load level as well as identify bottlenecks in the department. The Tennity ED leadership team has also been creative in implementing a COVID-19 hot zone as case counts rise and fall. They created a separate negative pressure “COVID suspect” assessment area and a COVID-19 hot zone with appropriate isolation rooms and personal protective equipment for higher-acuity patients in the acute care part of the emergency department.
Education and training for implementing the new model included:
- One-on-one meetings with each physician
- “At-the-elbow” coaching of all key roles in the new model
- Shift huddles
- Online training modules
- In-service presentations
- Information binders with one-page visual displays outlining the flow model, inclusion and exclusion criteria for each area, swim lane diagrams for the choreography of work in each area, high-flow processes (described below), and standard work for each role in each zone
The development of these one-page documents helped the team to formally standardize the work in the department for the first time in 10 years.
The Tennity ED implemented several other strategies:
- High-flow rescue: “High flow” refers to the surge state in the emergency department. The Tennity ED leaders and staff have hard-wired triggers for when a geographic area in the department is overwhelmed (particularly PIT and RTU, where patient turnover needs to be fast). In this model, the middle- and low-acuity patients are siphoned off to the RTU so the acuity and admission rate are higher in the acute care areas. They developed a system that brings another worker to an area experiencing high flow so it doesn’t get permanently overwhelmed and backlogged with patients. The front patient flow coordinators and back flow coordinator are trained to recognize and “turn on” the high-flow rescue.
- PIT to NIT: For emergency departments practicing PIT models, there is often a falloff in efficiency at night when the model closes down. The night shift, with its pared-back staffing, is vulnerable to surges, and the intake of middle- and lower-acuity patients can suffer. The Tennity ED frontline staff liked the abbreviated intake process so much, they did not want to shut it down completely at night. Instead of reverting to the old traditional nurse triage model, they run a nurse in triage (NIT) model. The nurse does the abbreviated intake and uses an established chief complaint–driven order set to quickly send labs in the PIT area before rapidly sending patients to the appropriate zone. As a result, the night shift not only comes into to an empty waiting room, all patients have been seen, have had labs drawn, and usually are roomed quickly.
- Epic support for workflows: Essential to these strategies was working with the Epic technology team at Eisenhower Health—Johnna Young and Susan Breshears—to modify the tracking board and create a PIT narrator to streamline the process. In this way, the IT system supported the new patient flow and workflow.
The results of the new process are in Table 1.
Nothing tells the story of the fantastic change implemented by the Tennity ED better the picture of an empty waiting room.