The characteristics of the Raritan Bay ED are outlined below:

Perth Amboy

Beds – 36
Annual volume – 47,000
Admissions – 17%
Length of stay discharged – 227 minutes
Left without being seen – 3.2%

As with most EDs, the most difficult process involved the appropriate segmentation of Emergency Severity Index (ESI) 3 patients. Most EDs triage nearly half of their patients into this group, and it encompasses a vast array of chief complaints and acuities. The Perth Amboy ESI distribution follows:

ESI Distribution

ESI 1 – 0.4%
ESI 2 – 11%
ESI 3 – 43%
ESI 4 – 33%
ESI 5 – 7%

The Raritan Bay improvement team came up with a segmentation scheme that allowed some ESI 3 patients to remain vertical while others were placed in beds. The guidelines for the ESI 3 vertical and ESI 3 horizontal patients are in Table 2.

(click for larger image)

Patients arriving were quickly seen by a “pivot nurse.” A pivot nurse is an experienced nurse with extra training in assigning patients to the segmentation model. The patients with triage acuity 1 or 2 or horizontal 3 went to one area, the patients with ESI indices of 4 and 5 and vertical 3 made up another stream. Patients were then quickly seen by a provider. Patients went to the area in the department with the appropriate resources for that patient.

Results:

Door-to-Doctor Time
BEFORE 45 minutes
AFTER 28 minutes

The Perth Amboy ED team has a great success story to tell. But even more, they have given ED practitioners a model to experiment with for the patient segmentation and streaming of ESI 3 patients, our biggest and most diverse bucket of patients. This is cutting-edge ED operations. Bring it on!

References

1. Jensen K, Crane J. Improving patient flow in the emergency department. Healthc Fincanc Manage. 2008;62(11):104-106, 108.
2. 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(3):241-249.
3. Kinsman L, Champion R, Lee G, et al. Assessing the impact of streaming in a regional emergency department. Emerg Med Australas. 2008;20(3):221-227.
4. Wiler J, Gentle C, Halfpenny J, et al. Optimizing emergency department front-end operations. Ann Emerg Med. 2010;55(2):142-160.
5. Welch S, Savitz L. Exploring strategies to improve emergency department intake. J Emerg Med. 2012;43(1):149-158.