Helen DeVos Children’s Hospital (HDV) is a 173–licensed bed private hospital and level I trauma center in Grand Rapids, Michigan. The emergency department sees more than 54,000 pediatric visits anually in its 27-bed facility, which has the ability to flex both space and staff during times of surge. It is operationally one of the most efficient (perhaps the most efficient) emergency department in the pediatric academic category. Table 1 compares its benchmarks with the Emergency Department Benchmarking Alliance (EDBA) and Academy of Administrators in Academic Emergency Medicine (AAAEM) data surveys of pediatric emergency departments.
Explore This IssueACEP Now: Vol 38 – No 07 – July 2019
HDV is a busy pediatric emergency department, seeing almost 150 patients per day. Astonishingly, it is able to put more than 1,900 patients through each treatment space per year (the typical pediatric emergency department moves about 1,500). Door-to-doctor times are a mere 11 minutes, and overall length of stay (LOS) averages are 95 minutes. This displays an efficiency that is unheard of across the country.
What are some of the secrets to its extraordinary efficiency? The physicians are members of Emergency Care Specialists, which staffs both adult and pediatric emergency departments, and the hospital is a Spectrum Health facility. Both organizations are known for innovation and operational efficiency. I spoke with one of the medical directors at HDV, Jackson Lanphear, MD. He practices both adult and pediatric emergency medicine and often brings innovative ideas from the adult emergency department to HDV. He, his co-director, Erica Michiels, MD, and their nursing leaders, Stephanie Flohr and Drew Peklo, run one of the most data-driven emergency departments in the country. Dr. Lanphear notes, “It is all about the data.”
First, after recognizing they deliver a lot of urgent care to the children and families in their community, they developed a flow model based on the patient population they serve (see Table 2). Note the lower-acuity breakdown.
HDV sees more Emergency Severity Index (ESI) 4 and 5 patients and fewer ESI 3. (It also admits fewer patients than average.) For comparison, an EDBA pediatric cohort with 75 emergency departments admitted 10 percent. Using this information, HDV created acuity-based zones. While ESI has been a good place to start in the streaming of patients, most ED stakeholders have found it is not a good LOS predictor. Therefore, the leaders developed a flow model (see Figure 1) that placed only 40 percent of patients in a traditional ED room and bed. This area, called Mod I, consists of 12 beds. Ambulances arrive there directly. Patients who can be treated and discharged in under one hour are streamed to Mod II, the Rapid Assessment Zone (RAZ).
There are two triage rooms where nurses do an abbreviated intake and then stream patients to one of the Mods. Providers in Mod II/RAZ start patients in a six-bed area. However, if the child will need more than 30 minutes of care, the child is moved to another area of seven beds designated as the “Extended Care” area. If a treatment bed is not needed, the patient may move to an internal waiting space. This fluidity in the lower-acuity zone is essential to efficiency and something most emergency departments should consider. In lower-acuity zones, the patient should not own the bed. Rather, movement in and out of beds to imaging or internal waiting rooms should be the norm. A patient bed in a low-acuity zone should only be occupied by patients needing diagnosis (a physical exam) or treatment (a procedure) in the bed.