Split-flow approach speeds patients to ED

Involve frontline stakeholders from the start

For the past few years, the ED at St. Mary Medical Center in Langhorne, PA, has seen double-digit increases in patient volume. The surging demand has been difficult, to say the least. And by early 2012, administrators realized it was time for a change in course.

“What we needed to figure out was how we were going to see 70,000 patients a year in an ED that was built to see 52,000,” explains Charles Kunkle, MSN, CEN, CCRN, BC-NA, the director of emergency, pediatric, and trauma services at St. Mary. “Truly, we were 18,000 patients above capacity, so we were really challenged.”

After reviewing several different throughput models, the administrative team found what they were looking for in the split-flow approach, an evidence-based practice that relies heavily on queuing theory or line management principles to minimize wait times and expedite patients toward the type of care they need.

“It’s not really about fixing the logistics of your institution. It’s more about looking at the processes and how you can reduce wait times at each stage as the patients move along,” says Kunkle. “How you implement split flow is specific to who you are and what challenges you face.”

In the case of St. Mary’s ED, the biggest challenge was limited space, coupled with surging demand. The percentage of patients being seen by a licensed practitioner within 15 minutes was hovering in the 60%-70% range, and this was impacting patient satisfaction.

“We did our research, went and visited some places [that had implemented the split-flow model], and then sat down with our operations improvement team and considered what we needed to do to make the model work for us,” Kunkle says. “Then we created our own version of split flow, and that was the whole idea.”

The results are impressive. In less than a year, the new model has enabled ED personnel to reduce door-to-physician times from an average of 47 minutes to 23.5 minutes, and overall length-of-stay in the ED for discharged patients has been slashed by 21 minutes. “Now, 99% of the time, people who walk in the door are seen by a nurse within 15 minutes,” says Kunkle. And there is good reason to expect continued improvement in the coming months.

Get back to basics

By the time St. Mary began implementing the new model in April of 2012, there were already plans in the works for a major $22 million expansion of the ED — a development that would clearly alleviate St. Mary’s space problems, but the ED’s administrative team moved ahead with the new model anyway, hoping to become adept at a vastly changed workflow before moving into expanded quarters. “We were able to develop the new ED based on the feedback and experiences we had with the split-flow model we put in place,” says Kunkle.

Under the new approach, the traditional triage process that used to take about 15 minutes was reduced to just a handful of questions that could be completed in three minutes. Kunkle acknowledges that the nursing staff at first balked at the notion that they could determine what kind of care patients needed without taking all their vital signs and going through the traditional routine, but he says it was a matter getting back to the basics.

Kunkle points out that you can tell a lot from a patient’s radial pulse and skin temperature, and if you are talking to people, you can see how they are breathing and observe their skin color. “We really had to get those triage nurses back to the art of nursing,” he says.

A more challenging aspect of this initial step was getting the nurses to carry out a mini registration process. “We did some specific training [on this aspect], and made sure we keyed in on the importance of identifying the patient appropriately,” explains Beverly Vanselous, RN, CEN, a clinical lead in the ED at St. Mary.

It took some time for the nurses to become comfortable with carrying out the basic elements of registration, but the approach is working smoothly now. “Initially, I wasn’t thinking real positively about having the nurses involved in registration, but the way it is laid out in our computer system, it really seems to work quite well, and we have had fewer issues that I thought we would,” adds Vanselous.

During the initial assessment, the nurse determines whether a patient should be sent to prompt care, pediatric care, acute care, or an expedited treatment area (ETA). The prompt care area is for minor injuries or conditions; patients with conditions or illnesses that are severe enough that they are likely to be admitted will go to the acute care area; and patients who require additional blood work, imaging, or other tests will proceed to the ETA. These patients tend to be those classified under the Emergency Service Index as level 3, says Kunkle.

“The level 3 patients are the ones that really take the longest because they don’t fit into any of those other categories,” he says. “They could be sick or not, and they are often the patients who fall by the wayside.”

Under St. Mary’s split-flow model, patients spend no more than 30 minutes in the ETA. Kunkle likens the way this part of the ED operates to the way a pit crew works in a NASCAR road race. “When a patient is put in a room, he will have a nurse, a physician, a tech, and sometimes a physician assistant who will all come into that room at once,” he says. “The physician asks the questions, and the nurses and the techs are listening so they don’t have to repeat the same questions.”

Scrutinize handoffs

One goal of the split-flow approach is to improve efficiency by enabling more tasks to be done at the same time, rather than in a linear manner, says Kunkle. What happens is the physician assesses the patient and orders whatever testing or procedures need to be completed, and then he or she moves on to the next patient, where the same process is repeated, he explains.

“The ETA is an area that is more labor-resource intensive because we only have 30 minutes from the time a patient arrives to get them assessed, get the initial set of vital signs recorded, and get tests and procedures ordered,” says Kunkle. Then the patients are moved out of the ETA to make room for incoming patients, he says.

One thing for ED managers to keep in mind if they are considering the split-flow model: You will be moving patients a lot, says Kunkle. And he acknowledges that this aspect of the model did raise some concerns among administrators initially. “In traditional EDs, you find a seat and you stay there. You own it,” he says. “We thought this would be a major issue for us, and that the patients would be upset.”

With patient satisfaction gradually rising, such concerns have eased. “In the old days, patients would sit and wait for us to see them and nothing would be happening,” says Kunkle. “Now, because we are turning people over quickly [in the ETA] and moving them out, the patients may still be waiting, but they are waiting for their tests to come back, as opposed to waiting there idly with nothing being done.”

However, the continued movement of patients from one area to another requires more handoffs than is typically the case. “One nurse isn’t staying with a patient from the start to finish anymore, so you have to be careful because you don’t have as much continuity,” says Vanselous. “Communication is of the utmost importance because the patient is going to start with one nurse and finish with another, and any time you are doing a handoff, there is a chance for a communication breakdown, so we really work on that very hard to make sure information is shared from one nurse to another.”

While handoffs require extra care, the approach enables charge nurses to spend more time on clinical intervention. “Before we implemented the new model, most of our time was taken up watching the waiting room and determining where patients would be placed,” says Vanselous.

Now a pilot nurse takes charge of driving the flow of patients. “It frees us up a little bit to support the nursing staff at the bedside,” says Vanselous. Further, split flow enables the ED to truly triage patients, she says.

“Before, it was more like we were doing data collection, and wherever there was a bed, we would put a patient,” she says. “Now, the sickest patients will go over to the emergent side, and other patients we send through our expedited treatment area, and it is a little bit like a staging area.”

With a variety of different pathways, the wait time to be seen is shorter. “It breaks that traffic jam,” says Vanselous. “We are not just placing patients in a bed. We can get them seen and move them out to a holding area or waiting area, and it just gives us more flexibility.”

Prepare for higher volume

Implementing the split-flow approach in a space-challenged ED hasn’t been easy, but staff now have access to more room, as construction has been completed on the first phase of the new ED, which includes an 18-bed emergent area for the sickest patients. Phase two, which will encompass a brand new ETA and some additional waiting space, will also soon be opened. Phase three and phase four should be completed by September.

The new ED is being built to accommodate the split-flow model, so administrators are eager to have access to the new layout, but Kunkle emphasizes that it won’t resolve all of the stress on the ED. There are still backlogs of patients being held in the ED while awaiting admission, so that will be the next issue to address on a hospital-wide basis, he says.

Kunkle’s advice to other EDs that are struggling with the same issues is to involve as many stakeholders in the improvement process as possible. “We had everybody involved [in the operations improvement],” he explains. “We broke the process down into steps and figured out how we could make it better according to the principles of split flow.”

Frontline staff representatives from nursing, pharmacy, radiology, and all of the other departments that work with the ED had a hand in structuring the process in a way they thought would work best. “The immediate engagement of staff helped to alleviate their anxiety because, oftentimes, when you come at people with major change that feels like it is being pushed from the top, it won’t work,” says Kunkle. “I was not a big believer in the operations improvement process, but I think it was invaluable time spent. Pulling each and every stakeholder into the room and getting their feedback, and then using their feedback, really did help us to implement this plan.”


Charles Kunkle, MSN, CEN, CCRN, BC-NA, Director, Emergency, Pediatric and Trauma Services at St. Mary Medical Center, Langhorne, PA.

Beverly Vanselous, RN, CEN, Clinical Lead, Emergency Department, St. Mary Medical Center, Langhorne, PA. Phone: 215-710-2100.