Improving emergency department patient flow at  St. Mary Medical Center

An innovative approach to ED performance improvement

Strong interim leadership

Philips consultants joined SMMC as Interim ED Manager and ED Director, focused on day-to-day operational and staff management. Leadership responsibilities included staff communications/relationships/support, hiring vacant staff positions and resource planning, staff development and training, assisting with conflict resolution, team mentoring, and more. They quickly became valuable leaders of the team.
 

A comprehensive assessment of key operational metrics was completed and a performance improvement (PI) engagement was recommended. Adding the PI program allowed the interim leaders to focus on team management while supporting the operational efficiency process changes.
 

A third consultant joined to focus on leading teams towards improving key performance indicators. The third consultant supported SMMC during these improvement initiatives and the two other consultants were asked to continue in the interim roles for the long-term.

ED Performance Improvement

The performance assessment included a thorough analysis of data collected for volume, arrival patterns, staffing patterns, ESI level distribution, ED billing visit level distribution, disposition breakdown, and length of stay. The consultants conducted interviews with administrators, departmental leaders, and staff, and spent considerable time observing ED patient flow, staff workflow, departmental processes, and communication.
 

Several areas were identified as needing improvement, including actions to:
 

• Revise front-end processes to include the intake and triage processes
• Re-educate staff on the ESI 5-level triage system
• Examine utilization of existing space to optimize workflow
• Implement standard work processes to addresses the frequent capacity issues in the ED
   

A PI work team was organized, led by Philips consultants and included SMMC physicians, administrative leaders, ED staff, and ancillary staff. The task was to collaboratively agree to an action plan to improve the ED walkout and length of stay rates.
 

The work team completed a deep dive review into each area identified in the assessment and leveraged the data analysis and stakeholder input gathered earlier. They developed recommendations for process change, prioritizing change initiatives which could make the greatest impact.

Middle-Trac patient flow process 

Key to supporting the PI recommendations was development of a new process solution termed ‘Middle-Trac’. Derivative of a split-flow process where patients are triaged quickly into parallel care streams, Middle-Trac focuses on patients in the middle (ESI level 3) who do not require immediate treatment. It keeps these patients vertical and moving through the department, not occupying valuable treatment spaces until a disposition decision is made.
 

Similar to an assembly-line, elements of the Middle-Trac process work cohesively. A triage nurse classifies arriving patients into one of three categories: immediate bed needed, fast track appropriate, and remaining Middle-Trac patient population. A detailed process flow maximizes continuity of care, manages essential resources, and minimizes provider hand-offs.