By Shari Welch, MD
Emergency departments serve as the front door for many hospitals, so the need for effective patient streaming flows has always been imperative. That said, the COVID-19 pandemic has caused patient volumes to surge in many communities and has presented ED leaders with the additional challenge of trying to mitigate the risks of virus contagion and spread. Now more than ever—safe care delivery is all about patient flow.
Sorting Patients Effectively
To those who understand ED best practices, sorting patients into acuity-based patient streams (also called patient segmentation) is the most efficient way to deliver care. For approximately 40 years, ED leaders have pulled lower acuity patients into what is most commonly known as the Fast Track. This is part of the Institute of Medicine’s aim to get the right patients to the right resources in a timely fashion. Dozens of scholarly works—including studies published in International Emergency Nursing, Emergency Medicine Journal, Western Journal of Emergency Medicine and Academic Emergency Medicine—have proven this sorting strategy is effective.
As ED volumes have grown (the typical pre-COVID-19 ED was processing 110 patients a day), the number and sophistication of patient streams increased and often included the following:
- Fast Track (for the least sick moved quickly in and out of treatment spaces)
- Mid Track or Vertical Model (for moderately sick patients treated often in lounge chairs)
- Major Care or Acute Care (for severely ill patients treated in a bed)
- Critical Care (for very ill sick or injured trauma patients)
- Admission Holding Area (for boarded patients who are stable waiting for a bed)
The most effective departments staffed these areas with medical teams, had internal waiting rooms to optimize the use of treatment spaces in each zone, and a physician in triage in charge of the complicated patient-sorting process. Having a physician handle sorting is also a best practice because they have a good idea of what resources will be required and how long the patient will need to be in the department.
COVID-19 Impact on ED Patient Flow
Once COVID-19 hit our communities, such patient streaming models were upended. Given the significant contagion factor inherent in the COVID-19 pandemic, and the difficulty in identifying those who may be infectious, ED arrivals in the age of the pandemic need even more sophisticated streaming. Factor into this the carrier capacity of the young, asymptomatic patients who appear well, and the ED intake process must protect vulnerable populations from the virus. We must design patient segmentation that will cohort patients and keep them safe.
In an ideal state, we will have rapid testing available upon arrival. Areas would be designated as COVID or non-COVID areas, as the chart below demonstrates. How much of the ED geography will be dedicated to COVID-19 will depend upon whether that ED is in a hotspot; Are you seeing one infected person an hour or possibly one infected person a day?
Patients who test positive will go to areas where the staff wear personal protective equipment. Wearing PPE is a game-changer, but it is not a simple matter. Donning and doffing the gowns or Tyvek suits, N-95 masks and gloves takes time and training, and it is often uncomfortably warm. Most providers can’t do it for more than four-hour stretches in full COVID-19 protection and yet they need protection from acute arrivals. Caregivers for patients with COVID-19 can’t care for patients who are free of the virus and vice versa. Doing so decreases staffing flexibility and impacts staffing and workflow on the front lines.
Additionally, ED leaders should be thinking about how patients can be screened without provider contact. Another important question to consider is whether there are patients who could be managed virtually with telehealth and no provider contact. Remember, once providers have had contact with COVID-19-positive patients, they run the risk of infecting other personnel and contaminating equipment. This risk of contamination makes a strong argument for delivering as much virtual care as possible and pairing medical scribes with providers. Working with medical scribes means physicians who have touched infected or high-risk patients as part of diagnostic or therapeutic care don’t need to touch computers and communication equipment and risk spreading the virus further.
The impact of COVID-19 on ED volumes and acuity has been stunning. According to the Emergency Department Benchmarking Alliance, most of the more than 1,200 ED members sharing data have seen ED volume down 40 percent since mid-March as patients have become afraid of the risk of infection. The acuity breakdown and admission rates are changing at some locations as well. That said, most do not think the 40 percent drop will be maintained into the summer. ED leaders will need to consider patient flow in their EDs from scratch and be informed by the data. The data can suggest the zones or service lines needed, their hours of operation, how many beds are designated and how each area should be staffed.
Shari J. Welch, MD, is a physician consultant for Quality Matters Consulting in Salt Lake City.