The University of Virginia (UVA) School of Medicine was founded in 1819 by Thomas Jefferson and is one of the oldest medical schools in the United States. In 1901, UVA opened its first hospital with 25 beds and three operating rooms. The medical center and undergraduate campus in Charlottesville still maintain the appearance of the original quaint colonial campus. But inside these charming historic walls is a research-driven, quaternary-care, academic, medical center.
Explore This IssueACEP Now: Vol 42 – No 11 – November 2023
The emergency department (ED) at UVA was rebuilt in 2019 and the department had not fully optimized its operations when COVID-19 hit. Following the pandemic, the ED saw a surge in its volume as it raced through 60,000 to 80,000 visits per year. (The ED went from daily volumes of 180 patients per day [PPD] to over 210 PPD.) In addition, daily variation increased. In one recent week the variation in daily census ranged from 160 PPD to 230 PPD. This volume and variation presented challenges when attempting to staff the ED appropriately.
The ED team was increasingly concerned about long waits, delays in care, and increasing numbers of walkaways, those who LWBS, or leave without being seen, and leave before treatment is complete, or LBTC. Though they were managing the boarding of admitted ED patients better than many academic medical centers, the increasing boarding burden on top of the surge in daily volume created an urgent need to restructure the ED flow. The hospital leadership, medical-school leadership, and ED faculty and staff partnered to engage in a radical re-engineering project they aptly named Excellence Driven.
They adopted a completely new flow model that allowed for acuity-based patient segmentation. While most academic EDs have lost pediatric volume, the UVA ED continues to see almost 20 percent pediatric patients. In addition, approximately 70 percent of the volume seen consists of middle- or lower-acuity patients. The ED team designed an elegant flow model that separates out the high-acuity patients and sends them to Major Care, while the middle and lower acuity patients go to the Minor Care area called the Rapid Medical Evaluation (RME), which is a combined fast track and mid track. Patients are treated in a vertical model in the RME.
Pediatric patients go to their own zone. Lastly, when patients are admitted, there is a functioning Admission Holding Unit that pulls those patients out of the acute-care areas to make room for newer acute patients. The ED leadership team also used this project to standardize how patients moved through the department to eliminate variation. They developed inclusion and exclusion criteria, time and volume targets for each zone, and swim lanes articulating the work of each role in every area. They also developed standard work documents for each role. This made it easier for everyone to know what was expected of them at work.
The important finishing touch for UVA Health’s Excellence Driven ED project was the development of real-time patient-flow leaders. The patient flow coordinator monitored flow into the department while the new charge nurse role monitored flow out of the department. These nurse leaders are tasked with overseeing everything related to patient flow. In particular, these nurse-leader roles include identifying early signs (triggers) that a zone is falling behind. This is particularly a risk in the front end of an ED. They identified strategic responses to each scenario. For instance, the physician-in-triage area can be overwhelmed by surges in arrivals. When the physician needs additional resources, another physician moves forward to help with physician-in-triage intake to get caught up. It is a short-term proposition, and such tactics around the country are often referred to as “high-flow” tactics. The overarching theme in high-flow strategies is to have standardized and articulated trigger-and-response strategies mapped out in advance, to be turned on in real time. The tactics typically involve the temporary deployment of personnel to an area to help when it is falling behind. High-flow strategies will depend on physical layout, staffing, and culture, and will be idiosyncratic to a particular ED. These real-time strategies being employed at UVA Health are cutting-edge operations and not yet embedded into many emergency department operations.
The before-and-after results of this sophisticated ED flow model are remarkable. Door-to-doctor time was reduced, but more importantly patients no longer flowed back into the waiting room, which had a profound impact on walkaways. Despite increases in year-over-year volume, all indicators show improvement in patient flow.
The operations team continues to optimize the new flow model, and multiple task forces focus on refining processes and staffing. Excellence Driven demonstrates the power of a multidisciplinary effort combined with creative problem solving and data-driven decision making.
Dr. Welch is a practicing emergency physician with Utah Emergency Physicians and a research fellow at the Intermountain Institute for Health Care Delivery Research, in Murray, Utah. She has written articles and books on ED quality, safety, and efficiency. She is a consultant with Quality Matters Consulting, and her expertise is in ED operations.