159 Creating Safety, Capacity, and Revenue in a Crowded Emergency Department: Impact of a Weekday Physician Intake Pod With a Vertical Split-Flow Model

Abstract

Though demonstrated improved efficiency and quality of care, the optimal structure, process, and shift coverage of physician-led team triage models have not been well described. Academic medical centers (AMCs) often present unique barriers to system redesign and structural changes. The primary objective of this study was to assess the impact of implementing a physician intake pod combined with a vertical split-flow model (PIP) using a Lean principles-guided, phased approach at an crowded safety-net AMC emergency department (ED). The study was designed as a nonequivalent control group study and implemented as a quality improvement project with statistical process control (SPC) charts for performance monitoring. The pre-implementation period (PRE; 1/16-10/16) was followed by the first installment of the PIP on weekdays 9a-4p (POST1; 11/16-6/17), then the second installment on weekdays 4p-11p (POST2; 7/17-11/17). There was no PIP implementation on weekends during the study period. The primary outcomes include door-to-doc (D2D), LOS (time to disposition), and left with being seen (LWBS). Secondary outcomes include ED boarding, hallway and chair utilization, ED capacity, and financial impact. All patients 18 years or older were included. Data was derived from the enterprise data warehouse. Two-factor ANOVA without a post-hoc Turkey Honest Significant Difference comparison was used for statistical analysis. No flow improvements were significantly demonstrated on weekends (p<0.0001). On weekdays, all primary outcome averages significantly improved compared to its previous period (p<0.0001). D2D (minutes): PRE (56.8), POST1 (37.2; difference -19.6 min; 95% CI -21 to -18.2), POST2 (27.1; difference - 10.1; 95% CI -11.7 to -8.4). LOS (minutes): PRE (297.3), POST1 (271.4; difference -25.8; 95% CI -29.7 to -22.0), POST2 (259.2; difference -16.7; 95% CI -16.7 to -7.7), with the majority of gains occurring during hours of implementation. LWBS%: PRE (2.66), POST1 (0.83; OR 3.27; 95% CI 2.83-3.76), POST 2 (0.23; OR 3.61; 95% CI 2.62-7.97). During PRE, weekends significantly (p<0.0001) outperformed weekdays (D2D difference 15.1 min, 95% CI 13.3-16.9; LOS difference 8.9 min, 95% CI 3.9-13.9; LWBS OR 0.31, 95% CI 0.25-0.38). During POST2, weekends were significantly (p<0.0001) outperformed by weekdays (D2D difference -15.2 min, 95% CI -17.7 to -12.7; LOS diff -19.5 min; 95% CI -26.3 to -12.8; LWBS OR 11.76, 95% CI 8.70-15.87). For each period, average adult daily volume rose: weekends (151,154,161), weekdays (161,172, 174). Vertical treatment space utilization rose significantly during all time periods. Boarding hours declined during PRE but rose significantly during post PIP installments. Total ED capacity significantly rose during all periods. On days of PIP implementation, POST2 created $150,000 of additional daily revenue and $50,000 of incremental daily net profit when compared to PRE. A weekday PIP outperforms weekends without PIP and improves ED flow with the majority of gains coming from the morning installment. A PIP creates functional ED capacity and is cost effective in a previously crowded ED, allowing more patients to safely be managed while significantly increasing revenue and profit generation. Without simultaneous back-end process changes, a PIP is associated with an increase in ED boarding as well as utilization of hallway and chair treatment spaces.