Split flow model?

[kat82]

Hi everyone-
Does anyone have experience in working in a split flow model ED? My ED will be going to a split flow model in a few months. My ED is quite busy, seeing 90k+ pts per year and our admission rate between 30-35%. We currently have a traditional model- during peak hours we have a critical care zone, 2 "main" zones, a fast track, a psych area, an obs unit, and a separate peds ED. Each zone is staffed with a team- doctors, nurses, techs, etc.

From what I've read, the split flow model seems to make everyone happier (patients and staff). I can see how shorter wait times and lengths of stay can make patients happier, but what I care about right now is, how does it improve doctor happiness? All I am envisioning more patients per hour- how will that make me happy??

I don't know very much about the proposed model other than a few slide shows that were presented at our faculty meeting with floor plans and statistics. If someone could shed more light, I would appreciate it.

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[Arcan57]

Hi everyone-
Does anyone have experience in working in a split flow model ED? My ED will be going to a split flow model in a few months. My ED is quite busy, seeing 90k+ pts per year and our admission rate between 30-35%. We currently have a traditional model- during peak hours we have a critical care zone, 2 "main" zones, a fast track, a psych area, an obs unit, and a separate peds ED. Each zone is staffed with a team- doctors, nurses, techs, etc.

From what I've read, the split flow model seems to make everyone happier (patients and staff). I can see how shorter wait times and lengths of stay can make patients happier, but what I care about right now is, how does it improve doctor happiness? All I am envisioning more patients per hour- how will that make me happy??

I don't know very much about the proposed model other than a few slide shows that were presented at our faculty meeting with floor plans and statistics. If someone could shed more light, I would appreciate it.

Split-flow works a little differently at every shop I've been at, but the basic premise is to adjust resource utilization to the patient's level of acuity. Typically this will consist of an "Intake" area where patients are seen and then moved to a "Results Waiting" area where ambulatory 3s, 4s, and 5s wait for lab results and disposition. Level 1s and 2s will continue to be brought back to the main ED and seen as normal. Variations include flowing all non-ambulance traffic through Intake (after a Quicklook nurse identifies they aren't a level 1 or 2) and different configurations of providers (provider keeps all Intake patients as primary, MD starts work-up, does screening documentation and hands off to second MD, provider hands off to MLP for disposition, etc) With enough providers and enough RW chairs/beds you can flow through insane numbers of patient per hour (my last system I could get the work-up and t-sheet started on 5-6 pts/hr while dispoing those that didn't need work-up in near real-time and keep up that pace for a 10 hr shift.

There are some issues with split-flow that have led our shop to abandon it then come back to partial split-flow and back again like some sort of drunken dance. Because you're moving more patients more frequently and you have more providers/nurses there are all sorts of ways it falls down.

In no particular order:
1) Eat what you kill - figuring out how to divide RVUs amongst multiple docs is something most billing companies aren't interested in. This can lead to the "Intake" providers keeping more prolonged work-up patients (especially if you're running a modified intake where all non-ambulance traffic flows through intake) in order to maximize revenues and for the Intake area to become a massive bottleneck.

2) Intake to RW provider communication - not an issue if they're the same person, otherwise they need to be in sync because RW it's going to be severely understaffed if you're trying to start work-ups there. Also, if the providers are of different types (MD to MLP or vice-versa) there can be some pretty uncomfortable conversations regarding practice styles.

3) As a corollary, you need to have decently firm rules about when a patient can be moved to results waiting since everything in the system incentivizes the nurse to move the patient to results waiting without drawing blood, etc. This leads to massive morale problems as RW is going to usually be staffed at 1:8 or so.

4) Not enough RW beds - during your peak times, the ED is going to be full and there needs to be hard decisions made about where the patients go from Intake. How comfortable are you sending them back to the lobby, do they stay in Intake until a bed in the ED/RW opens up, etc? A hospital with massive back end problems will see an initial benefit to split-flow but soon the number of sick patienat will cause it to clog up and then you have to decide if you still flow less sick patients through to keep the metrics good and leave the 78yo chest pain in the lobby, or you devote those resources to your sickest patients and accept that Intake grid-locks.

5) Most staffing models for nurses focus on ratios (1:3,1:4, etc). True split-flow requires more nursing resources than your standard model for the same number of Intake rooms because of queue theory and server times. For 6 Intake rooms where I was responsible just for starting the work-ups on 2/admittable 3s and dispoing everyone else, it was not uncommon for 3 teams of nurses and techs to be unable to keep up with the blood draws/EKGs I was generating without creating a backlog.

Split-flow tends to break down quicker in shops that have high admit volumes, relatively few Fast-trac patients, and prolonged in-patient boarding. From a doc standpoint, if you're hourly and not in Intake most of the patients you see are going to either be admits (basically it turns all the not intake area into the "major" side) and you're going to be sitting on the same patients if your hospital has back-end issues. If you are in intake you're going to run your ass off but it will be mostly low acuity. Trying to stick a midlevel alone in Intake doesn't work very well because they tend to get bogged down in decision making on the ambulatory 3s and the occasional 2 tht sneak by the Quicklook nurse. Wordy but I hope it helps. PM me if you have any specific questions.

 

[Greenbbs]

Hi everyone-
Does anyone have experience in working in a split flow model ED? My ED will be going to a split flow model in a few months. My ED is quite busy, seeing 90k+ pts per year and our admission rate between 30-35%. We currently have a traditional model- during peak hours we have a critical care zone, 2 "main" zones, a fast track, a psych area, an obs unit, and a separate peds ED. Each zone is staffed with a team- doctors, nurses, techs, etc.

From what I've read, the split flow model seems to make everyone happier (patients and staff). I can see how shorter wait times and lengths of stay can make patients happier, but what I care about right now is, how does it improve doctor happiness? All I am envisioning more patients per hour- how will that make me happy??

I don't know very much about the proposed model other than a few slide shows that were presented at our faculty meeting with floor plans and statistics. If someone could shed more light, I would appreciate it.

we have a split flow model in our adult ED and Peds ED (the concept is the same, the way it runs is slightly different as the adult ED)

first, some numbers:

2012 volume: 119+k

Provider shifts:
Adult: 7a-3p MLP x1 (Triage), 7a-4p Doc x2, 8a-5p MLP x1, 9a-6p doc x1, 10a-6p MLP or Doc x1, 10-10 doc x1 (Triage), 3p-12a doc x3, 3-12a MLP x1(Splits Triage and main), 5p-3a MLP x1 (Triage), 7p-4a doc x1, 11p-7a Doc x2, MLP x 1 (yes, we have a lot of shifts, but we have the volume to support it)

Peds: 8-4, 4-12, 12a-8a doc x1, 8-6p MLP, 11-9 MLP, 1-11 MLP, plus various resident shifts (peds residents rotate through, no adult ED rsidents)

43 rooms (total of 47 beds) adult (plus an alphabet soup land), and 16 beds peds with a small alphabet soup). We also have 10 beds in psych, and an obs unit for a total of 91 beds usable)

On the adult side, ALL patients that come through the front door go through the triage area staffed by an MLP, or the 10-10 doc. The provider sees the patient (either as the MSE, or as the treating provider). Things that need a major workup- neuro defects, cardiac type chest pains, etc get orders placed, and then are moved to the back. Ankle sprains, lacs, and other fast track stuff stays up front and gets treated. Peds is similar, but their hours are 4-12, and it's variable whether it's staffed by just an MLP or a doc. I'll just talk about the adult area for now.

The adult triage area has 4 rooms for treat and street, plus 4 rooms with chairs for minor workups (gastro needing IVF, r/o appy, vag bleed), and some other chairs (migraines, asthma needing prednisone and aerosol, etc). Depending on provider comfort, the things in the rooms can vary. I tend to keep some sicker patients in the rooms to decompress the back, where someone else may send the same stuff back to the main ED. Some ambulance traffic (fast track stuff) will also get shuttled to the front rather than the back. Our daily volume averages 350 or so a day, and we admit somewhere around 50-60 patients a day (so we have an enormous treat and release population).

It's not uncommon for the doc to see (i.e chart and dispo) 40-50+ patients in 12 hours working a triage shift (we have scribes, so the charting is done by the time you leave the room). It really helps on our door to provider time, where before we implemented this system in 2010, we had waits for door-to-doc of greater than several hours. Now, since it was started, we average less than 30 minutes on a consistent basis and now set goals of 20 minutes for door-doc times.

It also helps because we have a roving nurses for the alphabet soup patients, so when orders get put in up front, they get done extremely fast in the back while patients are waiting for a provider to see them. Usually by the time we get to them in the back, they're lined, labs are drawn, and imaging is in process.

The people who are sick make it back to get managed. The people who aren't get discharged immediately (I can get many things in and out in under 30 mins- simple lacs, etc. non-threatening rashes, muscle strains, etc can go much faster). Keeps our flow going rather nicely, especially because the hospital tries to move our patients out of the ED rather quickly (although we board a fair number earlier in the week because they still hold beds for surgeries, etc). ICU patients need to be out of the ED within 30-60 mins of admission per hospital policy. Most other patients will be moved from the ED to a hallway area, whether it's our EMS hallway, as we call it (the long hallway from the ED EMS entrance to the main body of the hospital) or to a hallway area on the floor. Our director actually used the hallway and outcomes studies and convinced the hospital that the patients would get better care, and they bit!

I think our split flow model works great. Sick patients get resources, while minor ones get in and out.