Explore This IssueACEP Now: Vol 33 – No 08 – August 2014
For emergency departments seeing medium to high volumes of patients, the concept of patient segmentation is becoming popular as a flow strategy.1-3 Patient segmentation means grouping patients requiring similar levels of care and having similar anticipated lengths of stay (LOS) into a geographic area with dedicated staff and resources. The earliest example of patient segmentation is Fast Track, which now has a very compelling body of literature behind it.3-6 Other newer examples of patient segmentation include:
- Geriatric ED
- Chest pain center
- Pediatric ED
- Critical decision unit
- Observation unit
SuperTrack was pioneered by Jody Crane, MD, in the Mary Washington Hospital Emergency Department in Fredericksburg, Virginia, as part of a complete patient-flow makeover.7 The Mary Washington ED was seeing more than 100,000 visits when it opened its new doors in 2006 and was plagued with front-end waits and delays. As part of a complete overhaul of its ED patient flow, Crane and his colleagues assigned patients to different patient streams in geographic zones based on their acuity. This included a so-called SuperTrack for the lowest-acuity patients. They saw a reduction in LOS, improvement in patient and staff satisfaction, and dramatic reductions in patients leaving without being seen (LWBS).
Similarly, Parkland Urgent Care ED (UCED), part of the Parkland Health & Hospital System in Dallas, tackled its patient-flow issues by employing a variation of SuperTrack in December 2012. Parkland representatives presented its findings at the ED Innovations 2014 Conference held in Las Vegas in Feb. 2014. The team reported experiencing staggering arrival surges. These arrivals were overwhelming existing processes, causing high LWBS rates (7.8 percent) and door-to-provider times (158 minutes) in Dec. 2012. The team decided to revamp both intake processes and the streaming of patients. It created processes and designated space for focusing on the lowest-acuity patients (Emergency Severity Index Level 5). It dedicated six rooms as SuperTrack from 8 a.m. to 6 p.m., where identified patients would be seen by a patient care team consisting of nurses and technicians. Patients had already undergone a medical screening exam by an advanced practice provider in triage. SuperTrack was also populated by other low-acuity patients who had protocol-driven orders. The SuperTrack chief complaints and criteria were very specific and included:
- Cold symptoms/congestion
- Headache, under 50 years of age
- Purified protein derivative placement or reading
- Suture/staple removal
- Dental pain
- Dysuria with positive urinalysis results
- Asymptomatic hypertension
- Sore throat
- Medication refill (with labs resulted)
- Cough less than two weeks’ duration
- Sinus congestion
Once patients were found to meet the SuperTrack criteria, they were quickly placed in a room, and a patient care tech (PCT) would expedite this process and alert the provider. This pull-to-full system for expediting SuperTrack patients was owned by the PCT and was an important feature of the new process. Providers can always reroute a patient if they feel that other information indicates a higher level of care is required. Providers simply place additional orders and communicate with the main ED team.
One of the key aspects of the initiative was having clearly defined resources allocated to the geographic space dedicated to the SuperTrack. Increasing the PCT staffing was also critical to the success.
The results of the initiative were remarkable! By December 2013, the LWBS rate had decreased to 1.4 percent, the door-to-provider times had decreased by almost a full hour (52 minutes), and patient satisfaction scores had improved. Other improvements included more efficient bed utilization, rapid room turnover, and increased nursing time with patients.
Using a new process, space, supplies, and staff dedicated to the care of very low-acuity patients, Parkland UCED improved all of its performance metrics, improved the overall flow of the department, and improved patient and staff satisfaction. I’d say this is a successful improvement initiative and that the SuperTrack is SUPER!
- Grouse AI, Bishop RO, Gerlach L, et al. A stream for complex, ambulant patients reduces crowding in an emergency department. Emerg Med Australas. 2014; 26:164-169.
- Ieraci S, Digiusto E, Sonntag P, et al. Streaming by case complexity: Evaluation of a model for emergency department Fast Track. Emerg Med Australas. 2008;20:241-249.
- Nash K, Nguyen H, Tillman M. Using medical screening examinations to reduce emergency department overcrowding. J of Emerg Nurs. 2009;35:109-113.
- Darrab AA, Fan J, Fernandes CM, et al. How does the fast track affect quality of care in the emergency department? Eur J Emerg Med. 2006;13:32-35.
- Liu SW, Hamedani AG, Brown DF, et al. Established and novel initiatives to reduce crowding in emergency departments. West J Emerg Med. 2013;14:85-89.
- Dinh M, Walker A, Parameswaran A, et al. Evaluating the quality of care delivered by an emergency department fast trackunit with both nurse practitioners and doctors. Australas Emerg Nurs J. 2012;15:188-194.
- Welch SJ. Using data to drive emergency department design: A metasynthesis. HERD. 2012;5:26-45.
Dr. Welch is a practicing emergency physician with Utah Emergency Physicians and a research fellow at the Intermountain Institute for Health Care Delivery Research. She has written numerous articles and three books on ED quality, safety, and efficiency. She is a consultant with Quality Matters Consulting and her expertise is in ED operations.