Picture the scene: You only need one or two items at the grocery store. You enter with the expectation that you will be able to grab what you need and depart without spending much time.
After obtaining your gallon of milk and loaf of bread, you present to the checkout lanes to find that the express lane is closed. Or worse, that all lanes are clogged with long lines of shoppers whose carts are brimming over with groceries.
Being a healthcare professional, you see a strong parallel to emergency department (ED) patient flow. As an ESI-level-4 shopper (one who demands few resources), you must now wait in the same line and succumb to the same checkout process as the level 3s, 2s and 1s (who, judging by their carts, need the checkout equivalent of advanced cardiac life support).
You look around for checkout clerks — or possibly a manager — who might notice that you only need to buy two items. Maybe they will open a lane or create a process just for you.
More and more ESI level 4 and 5 patients are utilizing EDs. According to a 2013 RAND Health report, there are several reasons for this:
- Lack of timely access (or any access) to a primary care provider
- Primary care providers are increasingly referring patients with worrying symptoms to the emergency room for their workups
Low-acuity patients (ESI level 4s and 5s) now represent 20 to 35 percent of all ED visits, according to the Agency for Healthcare Quality and Research. And they may be even more common in areas where access to primary or ambulatory and urgent care is limited.
ESI 4s and 5s who present themselves at EDs are often obligated to endure the same regimented processes as level 1s, 2s and 3s. While these processes are appropriate and necessary for seriously ill and injured patients, they are overly time consuming and resource depleting when applied to less acute patients.
Moreover, ESI level 4s and 5s often get placed into the same internal queues as the other ED patients — and have an appropriate tendency to get pushed rearward as providers address more emergent cases.
Unfortunately, ED staff members can sometimes develop an annoyance with these less acute patients, perceiving them as wasting their time and the ED's resources.
I think we all agree low-acuity patients do not need to be spending this much time in our EDs. So how can we deliver excellent care with a speedy discharge?
To start with, let's take a lesson from the local supermarket.
Virtual "Express Lanes" for EDs?
When kids with poison ivy and elders who have just run out of blood pressure medication present to the ED, they are a lot like shoppers who have run to the store for a gallon of milk. They don't need help scanning the groceries, bagging them or getting them to the car. They'd much prefer to use the express lane or self-checkout to speed up the process.
In much the same way, less acute ED patients benefit from expedited (and sometimes different) processes to move through the department from door to door. In other words, they benefit from the medical equivalent of an "express checkout" lane.
So how do we create such a system? Each ED is different, and a one-size-fits-all recipe is not realistic. However, the basic tenants of the methodology are to lean up the processes and time commitment to these patients — understanding that in these cases, providers can still deliver high-quality, patient-centered care while using fewer resources.
Some best practices:
Start at the door. Create a virtual express lane for the ESI 4 and 5 patients that allows for rapid pre-registration, abbreviated triage and vital signs and early provider interaction as soon as they enter the department.
Make them visible. Create special chart identifiers for low acuity patients so that when diagnostics, imaging or nursing services are needed, their cases receive expedited processing. Additionally, create a special notification or flagging system to trigger the rapid push of this patient's discharge.
Expedite final registration. Unfortunately, level 4s and 5s often end up behind higher-acuity patients in the registration queue. But this actually creates more inefficiency than it solves. In reality, the ESI level 1s, 2s and 3s usually spend more time in the department and therefore have a larger window of time to capture the final registration piece. So moving less acute patients to the front of the line actually increases efficiency and ensures that these patients are not waiting longer than necessary.
Streamline discharges. When low acuity patients are to ready to be discharged, create a process that quickly expedites their departure from the department.
Creating expedited care tracks for low acuity ED patients should not come at the expense of other patients' care. The trick is to pay Peter without robbing Paul — or any innocent bystanders. This is done by identifying where processes can be effectively leaned up and focusing on changes that move low acuity patients through the department and ultimately back out the door. Some examples include:
- Moving the ESI 4s and 5s forward in the queue for processing in lines where the others waiting won't suffer (for example, discharge registration)
- Constantly and dynamically moving resources (specifically nurses, physicians, PAs, NPs and ED technicians) from less impacted areas to attend to the "express lane" patients whenever the opportunity occurs.
Think of it this way. The ESI 1,2 and 3 patients typically consume resources and time commensurate with their respective needs. While it is possible to decrease the numerator in the TAT-D equation for these high acuity patients, the opportunity to carve out the biggest chunk is with ESI level 4s and 5s. Because these cases typically consume more resources than required, they have the greatest potential to affect the numerator in the TAT-D equation for all patients.
By quickly expediting the care of lower-acuity patients, we can effectively provide a virtual express lane to customers who expect to get in and out of our departments quickly. And just as at the grocery store, a speedy checkout is often more important than cheerful scanning and skillful bagging when it comes to delivering a satisfying customer experience.