Patients identified as needing to be horizontal are brought back to the main department as quickly as possible. However, the majority of patients arrive ambulatory and can in fact remain vertical. The physician can begin the patient encounter and diagnostics from this intake area, even if the patient then backflows into the waiting room. Patients can be assigned beds later and their care assumed by a physician in the back. Some patients may have a discharge from the front end. No matter how you choose to design your patient flow, patient care must have clear ownership. The best of these PIT models will identify an internal waiting room (which may be chairs along a hallway) for patients who have seen the PIT doctor. When that is not possible, part of the ED lobby can be cordoned off as a “Results Waiting” area using signage and perhaps theater rope.

This ad hoc PIT process is not optimal. We should all agree that we prefer to avoid delivering care in the waiting room. That said, this is becoming a survival tactic for many EDs. It allows patients to receive care when the department’s treatment spaces are all occupied by boarders. This process can be “turned on” in EDs of any size, whenever capacity does not match demand in terms of space. If there are physicians able and willing to see new patients, the model will be successful and shorten the length of stay for patients overall. For EDs with an existing PIT process in place, it can be expanded by adding an extra physician or opening the model for more hours in the day when boarding is extreme.

The ED at Sentara Leigh Hospital in Norfolk, Virginia (70,000 visits per year) turns a variation of the PIT model on during periods of high census. Teams including a physician will rotate to the PIT area and “swarm” patients (typically three or four patients in a row). The team begins the patient encounter, ordering tests and treatments. As beds become available in the back, patients are brought to rooms in their original team’s zone. They arrive with testing already begun. In this way the Sentara Leigh ED guarantees that every patient in the waiting room has an assigned physician and a care team. This is essential in the present-day ED with a high-risk boarding burden: Physicians and staff must own and manage the waiting room. The front end is ours. At Sentara they discovered that in this model, physicians are motivated to make disposition decisions in a timely manner to make room for their other newly arriving patients still waiting in the waiting room. With the implementation of this model, Sentara Leigh reduced their door-to-physician times and their walkaways by more than 50 percent.¹³