Vertical Care: One way to address overutilization and improve throughput.
Location
Central Division
Start Date
26-10-2023 10:30 AM
End Date
26-10-2023 10:40 AM
Description
Abstract:
Background:
Overutilization of Emergency Departments (ED) is a widespread problem in the United States, resulting in increased waiting times, causing more patients to leave without being seen (LWBS) and reducing patient satisfaction. During the triage process of assessing a patient, an Emergency Severity Index (ESI) score is assigned, ranging from 1-5 is assigned with higher scores indicating less acuity. Evidence supports that implementation of a dedicated space to quickly assess and treat patients with higher ESI scores reduces wait times, increases patient satisfaction, and improves LWBS.
Purpose:
To compare differences in patient waiting times, left without being seen rates, and satisfaction scores before, and after implementing a “Vertical Care” (VC) area to treat patients with higher ESI scores.
Methods:
In mid-2022, the ED Patient Throughput Committee, consisting of nurses and interdisciplinary professionals, collaborated to assess and treat patients assigned a lower acuity more quickly using a process they called “Vertical Care” (VC). First, the team identified a treatment space with private exam rooms where patients meeting criteria for VC would be assessed, and pertinent diagnostics completed. After collecting diagnostics, patients would be placed in a semi-private area with recliners to await results and an appropriate disposition (i.e., discharge versus hospital admission). The committee articulated criteria to determine appropriate patient placement in VC as follows: ESI between 3-5, ability to tolerate sitting upright, and absence of infectious or behavioral health diagnoses. From October to December 2022, twelve registered nurses and ED technicians trained as super-users for the VC area to determine who to refer to this area and how to efficiently treat referred patients. Prior to go-live, the Throughput Committee identified several outcomes to measure improvements including time to disposition, average length of stay (ALOS) for non-admitted patients, LWBS rate, and ED patient satisfaction.
Results:
From January to August 2023, the ED treated a total of 56,235 patients and 10,019 patients were placed in VC (18%). Several clinically and statistically significant improvements were observed in patient outcomes in the ED from pre (January 2022 to December 2022) to post (January 2023 to August 2023) VC implementation. Reductions were noted in LWBS rates (m=5.8% versus m=3.2%, p=0.03), time to disposition averages, (m=209 minutes versus m=162 minutes, p<0.01), and discharged ALOS (m=254 minutes versus m=229 minutes, p<0.01). Finally, patient satisfaction top box scores measured by Press Ganey surveys significantly improved in the ED (m=59.9% versus 70.2%, p value < 0.01).
Conclusion:
After implementation of VC, patients in the ED received a disposition more quickly, were less likely to leave without being seen, and reported higher satisfaction. Future work will focus on evaluating appropriateness of patient transfer to VC area versus the main ED and sustainability of the process.
Implications for Practice:
Implementing a VC process to treat lower-acuity patients assigned a higher ESI can contribute to better patient outcomes. Nurses should advocate to ED leadership to consider this model to ease capacity issues related to overutilization.
Recommended Citation
Chambers, Jacquenette, "Vertical Care: One way to address overutilization and improve throughput." (2023). Central Division Nurse Clinical Inquiry Conference. 23.
https://digitalcommons.providence.org/central_nurs_conf/2023/agenda/23
Vertical Care: One way to address overutilization and improve throughput.
Central Division
Abstract:
Background:
Overutilization of Emergency Departments (ED) is a widespread problem in the United States, resulting in increased waiting times, causing more patients to leave without being seen (LWBS) and reducing patient satisfaction. During the triage process of assessing a patient, an Emergency Severity Index (ESI) score is assigned, ranging from 1-5 is assigned with higher scores indicating less acuity. Evidence supports that implementation of a dedicated space to quickly assess and treat patients with higher ESI scores reduces wait times, increases patient satisfaction, and improves LWBS.
Purpose:
To compare differences in patient waiting times, left without being seen rates, and satisfaction scores before, and after implementing a “Vertical Care” (VC) area to treat patients with higher ESI scores.
Methods:
In mid-2022, the ED Patient Throughput Committee, consisting of nurses and interdisciplinary professionals, collaborated to assess and treat patients assigned a lower acuity more quickly using a process they called “Vertical Care” (VC). First, the team identified a treatment space with private exam rooms where patients meeting criteria for VC would be assessed, and pertinent diagnostics completed. After collecting diagnostics, patients would be placed in a semi-private area with recliners to await results and an appropriate disposition (i.e., discharge versus hospital admission). The committee articulated criteria to determine appropriate patient placement in VC as follows: ESI between 3-5, ability to tolerate sitting upright, and absence of infectious or behavioral health diagnoses. From October to December 2022, twelve registered nurses and ED technicians trained as super-users for the VC area to determine who to refer to this area and how to efficiently treat referred patients. Prior to go-live, the Throughput Committee identified several outcomes to measure improvements including time to disposition, average length of stay (ALOS) for non-admitted patients, LWBS rate, and ED patient satisfaction.
Results:
From January to August 2023, the ED treated a total of 56,235 patients and 10,019 patients were placed in VC (18%). Several clinically and statistically significant improvements were observed in patient outcomes in the ED from pre (January 2022 to December 2022) to post (January 2023 to August 2023) VC implementation. Reductions were noted in LWBS rates (m=5.8% versus m=3.2%, p=0.03), time to disposition averages, (m=209 minutes versus m=162 minutes, p<0.01), and discharged ALOS (m=254 minutes versus m=229 minutes, p<0.01). Finally, patient satisfaction top box scores measured by Press Ganey surveys significantly improved in the ED (m=59.9% versus 70.2%, p value < 0.01).
Conclusion:
After implementation of VC, patients in the ED received a disposition more quickly, were less likely to leave without being seen, and reported higher satisfaction. Future work will focus on evaluating appropriateness of patient transfer to VC area versus the main ED and sustainability of the process.
Implications for Practice:
Implementing a VC process to treat lower-acuity patients assigned a higher ESI can contribute to better patient outcomes. Nurses should advocate to ED leadership to consider this model to ease capacity issues related to overutilization.
