The Hospital of the University of Pennsylvania (HUP) was the nation’s first teaching hospital at the nation’s first medical school, now called the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. HUP had one of the earliest operating theaters, where surgeries were performed on sunny days between 11 a.m. and 2 p.m.—sunny days because there was no electricity. Some of the first anesthesia was delivered (whiskey and opium) to facilitate early surgical endeavors. Today, HUP remains prestigious, frequently rated among the top hospitals in the country and serving as a regional and national referral center.

And yet recently, the emergency department at HUP was struggling, as many hospitals do, with high boarding burdens. In 2018, the boarding burden exceeded 10,000 hours per month, translating into 16 lost beds in the 41-room emergency department, which was fielding 62,000 visits per year. Like many academic medical centers, HUP treats high-acuity patients.

High boarding times were associated with unacceptable waits and walkaway rates. In 2019, the new chair of emergency medicine and his ED operations leadership team (representing nurses, advanced practice providers, and physicians) decided an overhaul was needed. With support from HUP executive leadership, the ED operations team decided to dismantle the old processes and implement a package of innovations that were dramatic and complementary (see Figure 1).

Figure 1: ED Improvement Change Package

Building a Better Flow

Because it was getting harder to populate a fast track and there were high volumes of intermediate-acuity patients, the ED leaders designed a custom flow model that allowed patients who could remain vertical to go to a mid-track-plus area known as Forward Flow. Unlike other mid-track models around the country, which see exclusively Emergency Severity Index (ESI) 3 patients, HUP developed inclusion criteria that allowed many ESI 2 patients to be treated safely in a lounge-like chair. For example, low-risk chest pain patients could be served in the vertical model. This allowed offloading of the ED acute care beds, the most precious real estate in the department. In fast track (only open on weekdays), advanced practice providers independently saw the lower-acuity patients.

The flow model designed for the HUP ED 2.0 Project is shown in Figure 2. This is one of the most complex streaming models we have seen, yet it perfectly adapted to the realities of the HUP emergency department. Patient segmentation allowed for the appropriate placement of patients into streams with similar acuities and clinical intensity. Each acuity-driven zone worked to optimize its efficiency and throughput.