Reducing ER Overcrowding Without Adding Beds

FIRST TRACK

Unable to add physical beds, USACS developed a rapid medical evaluation model - which made more efficient use of the beds they had available. The new program, which was dubbed “First Track,” incorporated a small unit into ED operations, specifically designed to select out sub-acute patients in order to move the entire population more quickly and efficiently. These Level 3 patients tended to have the longest wait times, as opposed to the high acuity patients who get seen quickly and the low acuity patients who progress rapidly through minor care. The First Track program freed up many of the beds that had formerly been occupied by these patients - often for several hours.

During the process, patients are seen and treatment begins, but they are then transferred to a waiting area to await results, while their bed can then be used for the next patient. The First Track unit offers physician evaluation, administers and orders tests and x-rays and provides a small waiting area. Restaurant-style pagers were even employed to offer patients room to move beyond the ER.

THE IMPLEMENTATION PROCESS

The process to implement the First Track unit involved nine steps:

ONE | Engage Hospital Leadership

Implementation of a First Track unit changed work behaviors and challenged habits. Therefore, it was essential that everyone involved be committed and believe in the unit’s value. USACS engaged with hospital leadership, nursing leadership, and the physicians to ensure buy-in.

TWO | Identify Space

USACS identified a designated space within the ER. Ideally the designated space would have 4-8 beds and close access to a private wait area with 4-6 chairs. The workspace for nursing and physician providers would be fully independent with designated computer/hardware equipment to avoid the need to move far for printouts.

THREE | Obtain Equipment

In order to optimize throughput the First Track would be designed and equipped to operate independently from the main part of the department. For example, the First Track would have:

• Pyxis for commonly used medications
• Suture cart
• Gynecology supplies
• Computers & printers for instructions, prescriptions, order entry and label printing

FOUR | Establish Triage Process

USACS determined that patients routed through the First Track would be category 3. This means no patients in need of monitoring, just medications and observation from a chair while in the department. Category 1 and 2 patients would continue to be cared for in the main department, while level 4 and 5 patients would be treated in the minor care area.

FIVE | Manage Patient Expectations

Due to the various treatment areas, USACS anticipated that patients might feel overlooked, as later arrivals may be served ahead of them as a result of their acuity level. Managing their expectations from the moment of their arrival and triage would be pivotal.

SIX | Staff Education

The First Track process added complexity to the patient flow, requiring education so that the ED staff had the tools to manage patients effectively. Sub-acute patients would need to be handled separately from the rest of the population, from evaluation to receiving test results to processing out of the ED.

SEVEN | Identify Operation Hours

The ideal hours for the unit to function were determined based on several factors:

• Volume
• Acuity
• Staffing
• Other factors affecting ED throughput (i.e. hours of operation of an admission unit.)

EIGHT | Appropriate Staffing

In order to work efficiently, USACS assigned a dedicated physician, 2 nurses and a tech to the First Track unit. As necessary, these staff members were trained on entering orders and managing outside calls.

NINE | Ramp Up Period

As with any new initiative, USACS anticipated that the first 30 days would be a challenge. In order to maximize success, during the first several weeks the unit was staffed by the most efficient, engaged and productive nurses, techs and physicians.