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.
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.
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.