They then developed a patient-flow model that played to their strengths and their unique demographics. Rhode Island has unusually high emergency medical services utilization relative to the rest of the country. Forty percent of patients arrive at the AEC by ambulance. Imagine 120 ambulances arriving in your department each day! While the national norm is to bed ambulance patients upon arrival, this department did not have the capacity to immediately bed everyone who arrived by ambulance. Many ambulance patients, in fact, did not need a bed, and the leadership opted to save those beds for the sickest arriving patients. The AEC also has two other unique assets: strong nursing and a robust APP presence with a homegrown emergency medicine APP development program. The APPs have an average of nine years of experience and can function autonomously and efficiently.

(click for larger image) Table 1. Results of the AEC’s patient-flow improvement efforts

The hospital is confident that its nurses know sick when they see it, and so all patients, whether they arrive ambulatory or by ambulance, receive a very rapid nurse assessment taking fewer than three minutes. During this assessment, a chief complaint is obtained, and an Emergency Severity Index (ESI) score is assigned. Vital signs, allergies, and a pain score are recorded. All ESI 1 and 2 patients go to the prime care area, which consists of mirror pods with 16 beds each and a 16-bed critical care area for highly unstable patients, and they are immediately seen by a physician. All patients of low acuity with an ESI of 4 or 5 are sent to a fast-track area, named prompt care, and are seen expeditiously by an APP (see Figure 2).

Half of the nearly 300 patients arriving at the AEC each day have an ESI 3 designation (intermediate acuity). Across the country, we have begun realizing that this is a tricky patient mix and will include some very ill patients with occult medical problems. These ESI 3 patients are typically seen by a physician in triage in fewer than 20 minutes. This physician quickly begins the patient work-up and assigns the patient to an appropriate area within the department. If the physician determines the patient is sicker and needs an acute care bed, the patient can be sent to the prime care area, but most patients are sent for treatment in the lower-acuity focused care area and are treated in lounge chairs. The staff rapidly caught on to this new vertical flow model, which is being adopted and adapted to high-volume departments across the country.