Patient Segmentation: Redesigning Flow
Shari J. Welch · Emergency Medicine News · 2009
Once upon a time, the ED had a single treatment room in the basement of a hospital. As utilization grew, the footprint of the ED kept pace, and by the 1980s, most EDs had discovered that patients with minor injuries could be separated out from the department. With the right resources, patients could be treated and released more efficiently by creating a fast track for high census. In the 1990s, emergency physicians at higher volume centers found that some patients needed 24 hours to be diagnosed, treated, and discharged. This was the heyday of the ED observation unit. These innovations were the tip of the iceberg, and performance-driven emergency departments have been experimenting with models that segment patients into streams for more efficient health care delivery. (Healthc Financ Manage 2008;62[11]:104; Emerg Med Australas 2008;20[3]:241; Emerg Med Australas 2008;20[3]:221.) Other service industries have adapted this segmentation idea. Think of it like the service station that has one bay for brakes, another for emissions inspections, and one for oil changes or like a hospital cafeteria with a pizza station, a salad bar, and a grill. Imagine having all cafeteria patrons in one long line ordering these menu items; it would be hugely inefficient, but that is how we have operated emergency departments for decades. Patient Segmentation Some models currently being used in EDs include: Super Fast Track: Patients with abbreviated workups requiring minimal supplies, such as wound checks, dressing changes, simple sore throats, and earaches. Medical Screening Area: Similar to a fast track, all patients are evaluated by a physician or midlevel provider. The low-acuity problems are managed in this area, and more complicated patients are sent to other zones based on patient segmentation. Fast Track and Pediatric Fast Track: Patients with sprains, contusions, muscle spasms, simple nondisplaced fractures, or lacerations are treated here. Treatments for children also may include small foreign body removal from the nose or ears and newborn corneal abrasions. Supertrack: This track may include simple common medical conditions that can be diagnosed using point-of-care testing, such as urinary tract infection, mononucleosis, blood sugar, pregnancy, uncomplicated nosebleeds, and hematocrit. Absolutely critical to the successful implementation of this service line is having supplies nearby. In all of these service lines, the patient occupies a bed or a space for a short, finite time. Each service line operates in a clearly identified geographic zone, and has a results waiting area for patients. The patient only occupies a care space for as long as he is being assessed and treated. While waiting for imaging or lab test results, the patient moves to a results waiting area. The idea of keeping patients vertical and not committing them to a bed for their stay is new to emergency medicine. Approximately 85 percent of all ED patients nationwide are discharged, and this idea makes sense in these days of overcapacity. Research has shown that even the elderly prefer to sit over being made to lie down. Follow-up IV Therapy: Adjacent to any of the zones, any ED with more than 40,000 visits and more than seven percent follow-up visits should consider this innovation. Because more and more patients are being treated as outpatients, receiving antibiotics daily and not being admitted, the ED needs to evolve services for this care. One ED collected a bank of recliners with a television on the wall, streamlined the paperwork for staff, standardized the follow-up process, and moved patients in and out of its IV therapy zone without tying up precious rooms. Main ED: This area is for patients who need labs or x-rays but who the physician anticipates discharging. Examples include soft chest pain, presumed gastroenteritis, renal colic, and trivial overdoses. This area operates traditionally, with patients spending some time in an ED room. Clinical Decision Unit: For segmentation to this service line, there should be a better-than-average chance that the patient will be admitted, even though diagnosis might take six to eight hours to determine that. Examples include chest pain requiring stress testing, abdominal pain requiring contrasted CT, crisis intervention, subspecialty consultations, and MRI. Observation Unit: This unit is for patients who may need 24 hours of observation but likely not hospital admission. Appropriate cases might include acute asthma, renal colic, unspecified abdominal pain, intractable vomiting, unsuitable home situation, sickle cell pain crisis, transfusions, soft tissue infections with vomiting, pneumonia or pyelonephritis with vomiting, intractable back pain, congestive heart failure, or atrial fibrillation. At 24 hours, patients are converted to an admission or discharged. Acute Care/Resuscitation: These rooms may be designated as trauma or medical, and this zone should accommodate team care, such as the trauma team or the stroke team. It is for patients with unstable vital signs, who have been intubated, and those requiring critical care or resuscitation. These patients should be moved as quickly as possible to an intensive care unit; their stays in the ED are short. Most testing would be done at the bedside. Express Admission Unit: Inpatient bed waits are a major constraint to smooth ED patient flow, and this unit is for patients who are waiting for a room. One solution is to house these patients in a small zone to free up patient rooms. One model is to place this zone next to the clinical decision unit or the observation unit. Chief Complaint-Based Unit: Many EDs are experimenting with chief complaint-based patient segmentation with chest pain units, abdominal pain units, and pediatric units, all as zones within a main ED. The take-home message is simple and exciting: The ED of tomorrow won't look like the ED of today. The old processes won't serve practitioners or patients in the future as ED volume and demand continue to grow. The best changes will come from front-line staff like you thinking outside of the box. On your next shift, walk around the department to see how you could create work zones. Think about adapting your workspace to your workflow. Look at your census data, plan the service lines that would best serve your department, and consider how to develop those strategies.