The ED at Texas Health Fort Worth was designed as an I-beam configuration, with five zones that care for patients based on triage acuity (see Figure 1). The most recently arrived physician treats the sickest, least stable patients in the critical care area.

(click for larger image) Figure 1. The care zones at Texas Health Fort Worth emergency department.

Physicians progress through a schedule that has them move from the highest-acuity area to the lowest-acuity area (Critical Care –> Medical A & B –> Quick Care) during a shift. Procedures are handed off to a procedure physician who only does procedures. This will probably be the most controversial aspect of this scheduling paradigm, but it’s explained by Terence McCarthy, MD, in a way that every emergency physician understands. If you’re intensely involved with a patient who may be septic but you also have a three-layer facial laceration to close and are interrupted and distracted, you may feel afterward that you did not do your best. Imagine if all you had on your plate were procedures done in series. Since every physician works through the progression, every physician has the opportunity to perform procedures. The model is also noteworthy for placing the most rested physicians in the area with the most clinically complex and ill patients. The shift finishes in the minor care area, which excludes patients with abnormal vital signs. Physicians are encouraged to make efficient and rapid dispositions of these patients because if they are unable to tidy up a zone as they progress through it, then they may have active patient care going on over a large ED footprint. The physicians admitted that, on occasion, the geography and the physician-progression model seem at odds and a physician is doing a lot of running, but the doctors explained that their model had many advantages viewed as, “what is good for the patients.”

The proof of physician satisfaction is in the retention pudding. Texas Health Fort Worth has very low staff turnover. When asked about the last time a physician left the group, Richard Dixon, MD, and Dr. McCarthy scratched their heads. “Remember in 2002?” Both physicians and nurses are screened for a high work ethic and standard and good teamwork skills. The glue that seems to hold it all together is a genuine commitment to the patient.

This innovative model for staffing and the delivery of patient care goes against the conventional wisdom of med teams in a geographic zone, but it clearly works. That said, it requires a high level of teamwork and collaboration, a culture of putting patients first, and a commitment to continuous improvement. If you have all of this going for you, this is a care-delivery model that is worth exploring.