Planning for Higher Volumes

When the department exceeds capacity (which is not a daily occurrence), there is a mechanism to open a third eight-bed area, called Mod III. Interestingly, the Mod III area was originally conceived as an observation unit, but in practice, they were unable to consistently populate it with patients. This is turning out to be a common situation in pediatric emergency departments nationwide. As productive and useful as ED-based adult observation units have proven to be, pediatric observation units have not proven as successful a concept in practice. Dr. Lanphear points out that, unlike adult emergency medicine, pediatric emergency medicine does not have many conditions that easily populate an observation unit year-round (like chest pain, mild congestive heart failure, and chronic obstructive pulmonary disease). Many observation-appropriate conditions (pediatric respiratory illnesses and dehydration) can run in seasonal patterns following viral transmission. This makes it hard to populate such a unit year-round. In addition, many pediatric emergency physicians have noted the difficulty in predicting which patients could be successfully turned around in the observation unit, creating myriad regulatory and compliance concerns.

(click for larger image) Figure 1: Helen DeVos ED Flow Model

The HDV emergency department also created a model of flexibility in scheduling. Shifts match the patient arrivals, not physician or nursing preference. There are daily shifts called “at-risk shifts.” Providers come in for a four-hour shift but know they may stay four to six hours longer depending on the situation and conditions in the department. Physicians and nurses huddle to decide the strategy for opening and closing areas and sending providers home in real time. They have well-articulated processes for most contingencies.

All decisions about zone size, opening and closing areas, and staffing are based on data. HDV is one of the most data-driven departments I have encountered. Decisions are based on what is best for the patients and their parents, not on provider preference. Look at the success that this overarching theme has brought. 

The Helen DeVos leadership team (from left): Stephanie Flohr, Drew Peklo, Erica Michiels, MD, and Jackson Lanphear, MD.
Credit: HDV