In the continuing quest to minimize wait times and enhance operational efficiency, clinicians and administrators have developed many patient flow models, most of which tend to work best in EDs with specific characteristics or patient populations.
Sometimes, a unique model emerges that is worth considering for ED leaders who suspect there is more they could do to optimize their resources and serve patients more efficiently. For instance, recent research suggests the development and implementation of a rapid assessment zone (RAZ) model has produced positive benefits for the ED at St. Luke’s Hospital in New Bedford, MA, a busy, community ED that averaged about 90,000 patients a year as of 2017, the period during which the RAZ model was first implemented.
In a retrospective before-and-after study, investigators found the RAZ approach enabled the ED to cut the average arrival-to-provider time in half, trim overall length of stay (LOS) by 32 minutes, and reduce the leave-without-being-seen rate by 84%.1
It is an ongoing journey for the St. Luke’s ED, but the results suggest the RAZ model may be an approach that other similar departments may find useful as they examine their own operational metrics and pressure points.
The St. Luke’s development team members did not start from scratch when designing their own approach. They borrowed elements from other front end optimization models, but also looked closely at their own data to devise a solution best suited to facilitating throughput, given their environment, staff, and patient population.
Jennifer Pope, MD, a co-author of the study and an emergency medicine physician affiliated with both St. Luke’s and Beth Israel Deaconess Medical Center in Boston, explains there are two main components to the RAZ model: an up-front triage decision and the RAZ space itself.
“[A] rapid split was developed in response to an analysis of [the ED’s] old process, which found there was a lot of time lost performing a detailed triage process up front,” she notes. “The ED had been trying to compensate by using a lot of nursing-driven triage protocols, which can be very helpful when short on clinical space, but also [can] lead to overtesting.”
Consequently, the RAZ model essentially eliminates traditional triage from the intake process and employs a “pivot nurse” to quickly determine whether patients can remain ambulatory or likely will require more intensive resources. This determination is based on the nurse’s clinical judgment, a patient’s age, and primary complaint. The decision is made before any vital signs are taken or an Emergency Severity Index Score designated.
The pivot nurse’s determination is used to split the flow of patients between the main ED, a 49-bed area that receives patients who will likely require more resources, and the RAZ, a space that includes 18 rooms equipped to manage the patients who can remain ambulatory.
“The RAZ space and its function [have] both planned and organic components,” Pope observes. “St. Luke’s is a relatively large-volume ED, but has a low volume of true [lower acuity] patients.” Further, Pope notes the large waiting room in the original ED offered an opportune space from which to carve out additional ED care spaces.
“We created one large patient care space as opposed to multiple small ones, which meant [the area] would need to care for a broader acuity of patients than a fast track [typically would],” she says.
Once patients are placed in the main ED or RAZ, they will undergo a provider assessment, vital signs will be taken, and a full nursing triage assessment will take place. The idea is for these actions to occur as concurrently as possible to remove unneeded extra steps and minimize serial assessments, according to investigators. Further, bedside registration is completed when it does not conflict with patient care.
In most cases, patients sent to the RAZ will be diagnosed and treated while ambulatory. Patients sent to the RAZ who are identified as requiring more resources than originally determined may be transferred to the main ED, although their care can begin in the RAZ.
When space is not available in the main ED, the RAZ can be flexed to include some acute care space. Typically, the pivot nurse, in concert with the ED lead nurse, makes such determinations.
During the intervention study period, which began in June 2017, the RAZ was operational every day between 9 a.m. and 11 p.m. and staffed by four nurses, three clinical technicians, a physician, and two advanced practice providers. Notably, the approach did not require the onboarding of any additional staff.
To assess the impact of the model, investigators compared data from the six months before the intervention began with data compiled for six months following implementation of the RAZ. Both the pre- and post-intervention periods included more than 43,000 patient visits to the ED. Investigators reported the RAZ model produced improved outcomes on all metrics studied. This included an overall median ED LOS decline from 203 minutes to 171 minutes, a decline in the median arrival-to-provider time from 28 minutes to 13 minutes, a decline in the leave-before-treatment-completed rate from 1.0% to 0.8%, and a decline in the leave-before-being-seen rate from 3.1% to 0.5%.
While the intervention proved successful, one early hurdle concerned creating a “greeter” position. The person fulfilling this nonclinical role is responsible for managing a quick preregistration and recording each patient’s primary complaint upon presentation to the ED.
“A major challenge was getting the greeter team comfortable with the role,” shares Pope, explaining that the greeter and an ED tech are the first employees to see incoming patients. “The pivot nurse is often able to make the decision [regarding] patient flow without seeing many of these patients.”
To assist with this task, Pope notes that the development team created a ‘trigger’ mechanism that the greeter can use for patients who require immediate attention. For instance, the greeter would call “trigger” for any patient in obvious distress, someone who is unresponsive, or someone who has been stabbed.
The authors stated the model includes flexibility for patients who present with certain complaints such as chest pain. In that instance, for example, a patient will receive an ECG before the pivot nurse’s decision regarding placement in the RAZ or main ED. Also, they noted plans are in place to adapt the RAZ model in the event of patient volume surges.
Considering the pivot nurse plays a key role in the RAZ, the individuals chosen to serve in this position initially were experienced nurses who were well-versed in rapid triage, Pope explains.
“Some had been part of the RAZ development team,” she says. “Over time, we have seen the role performed successfully by a broad cross-section of nurses who have rotated into the role and who have received training from nurses experienced with the model.”
Pope adds the RAZ team continues to examine the model for new iterative changes that might further enhance performance. “[This includes] taking a closer look at the pivot [nurse] role and improving the process for moving patients out of the RAZ when they are more complex/sick, and main department beds are limited,” she shares. “Any major change should be accompanied by a regular examination of data, discussion with front-line staff regarding challenges and barriers, and the understanding that healthcare demands flexibility and agility in navigating a field that changes constantly.”
For other ED leaders who face similar throughput challenges, Pope cautions that a front-end improvement will produce few dividends if the process happens in isolation. “There was a lot of work done prior to [implementation of] the RAZ focusing on internal and back-end ED operational processes and metrics,” Pope explains.
These improvements focused on things such as lab and radiology turnaround times and streamlining the admission process. “These other processes need to be examined and optimized thoroughly to best understand what front-end process a department needs,” Pope adds.
- Anderson JS, Burke RC, Augusto KD, et al. The effect of a rapid assessment zone on emergency department operations and throughput. Ann Emerg Med 2020;75:236-245.