'Split flow' slashes statistics for LWT, LOS

More staff required to implement new strategy

The ED at Baptist Medical Center in San Antonio has slashed its left without treatment (LWT) rate from a high of 9.5% in spring 2009 to 2.2% at present, thanks to a "split flow" strategy it adopted in August 2009. During the same time period, total length of stay (LOS) has gone from 393 minutes to 120 minutes in January 2010.

"We had a lot of problems with patient satisfaction and wait times," recalls Jim Davidson, MD, the medical director. "We very frequently had [Press Ganey] numbers in lower than the 10th percentile, but now we typically hit numbers at least in the 70s, and had one month where it was in the 99th." This program has been implemented at four of the five EDs in the Baptist Health System. "We have seen comparable improvements across all EDs utilizing split flow," notes Samuel Spencer, director, operational excellence.

In addition, notes Gina Grnach, RN, administrative director of emergency services, "Our average door-to-provider time was around 93 minutes. Now our best time has been 56 minutes."

The new process was modeled after the one used in Houston Memorial Hospital and Banner Health in Arizona, notes Grnach. "Our [Six Sigma] black belt used to work at Houston Memorial, so she knew about it," she explains.

ED representatives went to Houston, and came back and customized the model to meet their specific needs and resources. "We have a very old ED, and we had to make adjustments," she explains. For example, the Houston ED has two entrances through which patients can access the ED, while Baptist only one. "We have one door, not separate ones for EMS and ambulatory patients," Grnach explains, "so all our patients come through the same way." To deal with that shortcoming, several rooms were redesigned, and acute care was put up front, Grnach says.

Under the new system, patients with an emergency severity index (ESI) score of 1, 2, or 3 (3 can go either way) are higher-acuity patients and are taken to the front or acute side of the ED, while 4 and 5 are lower acuity or less urgent and are taking to the "intake and procedure" rooms. Grnach explains. "We do a quick look, asking five questions, and then the triage nurse makes the determination as to where (which track or flow model) they will go," she says. The questions cover vital signs, complaints, allergies, name, and date of birth.

Patients who are expected to be treated and released are taken to one area of the ED to receive tests and wait for the physician (intake and procedure). Patients who are more urgent and/or are expected to be admitted are taken to a different area for treatment (acute bed). In intake and procedure, the provider sees the patient and orders necessary tests and examinations. The patient then is taken to "results pending" to await results and prepare for discharge. Meanwhile, the intake and procedure bed is opened up for the next patient, thus increasing patient flow.

"We added a PA or an NP in the back for intake 12 hours a day during peak times, and I added another RN and a tech," Grnach says. "We made sure we had a tech in triage so if the nurse had to leave, he was always out there. The other two techs are in the back end."

A "results pending" section is located on the opposite site of the department from acute care, Davidson says. "We had curtained areas for eight patients, so we set up chairs and put a TV in there," he adds.

In the past, when patients presented, the triage nurse would try to see them within five to 10 minutes, says Davidson. "Patients with very low acuity would have to wait around before the doctor could see them," he says. "Frequently, they had been waiting five hours or more when that happened.

While pleased with the performance of the new process, he is not resting on his success. "I don't yet feel comfortable with our consistency, and I want to get the LOS down more," Davidson says.

Daily monitoring has helped the department stay on top of the new process, he says. Grnach says, "I walk around and report daily to administration. So, for example, if I report it takes two hours to get all patients in our department into a bed, we'll work with the other departments to get a quicker discharge." The other departments include the lab (turnaround) to housekeeping (getting beds cleaned more quickly), she says.

Staff are involved in new process

The ED staff helped develop the new split flow program at Baptist Medical Center in San Antonio. "They helped work on the different processes, for example, how to ensure the chart got from place to place without getting lost," says Gina Grnach, RN, administrative director of emergency services.

This involvement was necessary because the department uses paper charts, she reports. "We have the chart in the intake area. When the patient goes to 'results pending,' the chart follows him there because we do not want the doctor running around looking for it," says Grnach, explaining that the nurse will move the chart.

Preparation for the new process was not always easy. It began with a three-hour training class. "It was hard for the nurses, because it was a total change in procedure," she says. In the past, if patients came into a room, they "owned" that room and the nurse. "Now, they may see two or three rooms and nurses," Grnach says.

However, she adds, "Now everyone is on board, and no one wants to go backward."