The emergency department (ED) at Scripps Mercy Hospital San Diego is a different breed of ED. This can be felt upon entering the beautiful southern California facility through the patient entrance. During my visit the greeter area was quiet, uncluttered, and virtually empty at 4 p.m. Seeing more than 76,000 annual visits, this urban academic Level I Trauma Center is a STEMI-receiving hospital, geriatric emergency department (GED) certified, and a Stroke Center.

Other operating characteristics for this department are seen in Table 1. Interestingly, the geriatric rate is higher than the average for similar departments, and the pediatric rate is lower—both suggesting a higher acuity patient mix—yet the admission rate is only 21 percent. The EMS arrival rate is quite high and this is challenging from an operational standpoint. They have a high behavioral health (BH) population but only modest boarding.

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The operations playbook of best practices for EDs in the 60,000–80,000 annual visits volume band is now well recognized and includes the following features:

• a physician in triage (PIT) intake process to ensure the timeliness of the patient/clinician encounter, even during times of surge and high boarding when the department is likely full,
• acuity-based patient care zones with like patients being treated in one area,
• a “fast track” for extremely low acuity patients who may be treated by an advanced practice provider (APP),
• a “mid-track” or vertical care area where middle acuity patients remain vertical to receive diagnostics and therapeutics, and are likely discharged home,
• an acute care or major care area reserving patient beds for the sickest patients that are likely to be admitted, and
• team-based, zone-based care delivery with a care team (physicians, nurses, and techs) all taking care of the same patients in a pod or a zone.

Doing Things Differently

The ED at Scripps Mercy Hospital San Diego does not have a PIT process. Instead, it actively pushes patients into care spaces. The department does have acuity-based care zones. Care is provided largely by teams in acute care zones. That said, the department incorporates floating and flexibility in the name of efficiency: Care of patients in hall beds and in the fast track is shared among all clinicians instead of using dedicated ones in those areas.

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In fact, their patient flow model is more typical of a low-volume ED (see Figure 1).

In addition, the Scripps Mercy San Diego ED is unique in terms of its physician group: Pacific Emergency Providers (PEP), APC, is a single-department, independent, democratic physician group with 15 physician partners, eight APPs, and a cadre of other full-time and part-time practitioners. APPs function in a supportive role to physicians and every patient is seen by a physician!

PEP has had this contract for 20 years and is closely aligned with their hospital leadership. The hospital leadership does its part to support the emergency physician group by keeping the boarding burden to a minimum (103 minutes versus 189 minutes EDBA benchmark) and by providing efficient ancillary services, particularly imaging. Turnaround times for all imaging modalities are faster than recorded benchmarks.

Does this atypically staffed and run department work? As you can see in Table 2, PEP is an unusually high-performing ED.

How Do They Do It?

How does this department do so well without using all of the best practice tactics of other departments of the same volume? It all comes down to culture.

Both physicians and nurses are recruited to find stakeholders who share the same work ethic and commitment to efficiency, quality, and courtesy in caring for patients. On my tour, I was impressed at how often I heard the phrase “this is better for the patient.” Conversely, I did not hear “that is not my job” or “that is not my patient.” These “all-hands-on-deck” and “patients- first” imperatives embedded into the culture at Scripps Mercy San Diego are palpable.

The Scripps Mercy San Diego ED is continuously trialing improvements and this changeoriented culture has bred amazing innovation. In particular, they have responded to the BH crisis in their community by adopting BH order sets for patients awaiting psychiatric evaluation and placement. The ED has cordoned off four rooms to create a BH pod that moves these patients to a quieter area. The physicians have become comfortable discharging a high percentage of patients with BH issues and are comfortable with a number of BH therapeutic interventions for the sickest patients. They have gotten proficient at treating substance abuse and are credentialed to prescribe buprenorphine and naloxone (Suboxone) for patients who will follow-up in appropriate settings.

Because the ED has overperformed for many years, it has been rewarded with many amenities including a case manager 12 hours a day, 24-hour critical care/intensivist coverage, and 20-hours-a-day clinical pharmacist coverage.

The culture at Scripps Mercy San Diego is unique and hard to find. The department was extraordinarily quiet as I walked through, and yet there was an urgency to see the next patient, to make the next disposition. There was little tolerance for waits and delays, and the entire department was rowing in the same direction to keep the waiting room empty. This ED is a lesson on how a shared culture can overcome many ED obstacles.

No matter the operating model, an ED will likely struggle with achieving results without a strong team culture that puts patients first. I can’t argue with the success story that is told by this department’s metrics. And it all comes down to culture!

Dr. Welch practiced emergency medicine for 35 years. She was an emegencry department (ED) quality director for Intermountain Healthcare. 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, patient flow, and work flow.