Patient Flow Solutions

New 'Patent Accelerated Care Environment' aims to facilitate work flow, free up ED for acute care needs

Novel approach relies on efficiency rather than size to handle surging volume

With surging demand for emergency care, many hospitals across the country are building larger EDs or expanding existing facilities to make room for more beds. Bucking this trend, however, is Virginia Mason Medical Center (VMMC) in Seattle, WA. Yes, the health system has a brand new ED that just opened its doors to patients in November 2011; however, at 17 beds, the new ED is actually smaller than the old department. But alongside the new facility is an 18-bed Patient Accelerated Care Environment (PACE), a brand new unit that is designed to help the ED and other areas of the hospital operate more efficiently while also connecting patients with the care they need quickly.

"We downsized our waiting room, as well as our bed capacity in the ED to be able to facilitate the care of just those acute patients who are coming into the ED," explains Sharon Mow, MSN, the ED director. Patients who need a few hours of care but do not require admission are quickly moved over to the PACE unit. Also destined for the PACE unit are patients who are in the process of being discharged, as well as the patients who are being prepared for admission. These patients are moved to the PACE unit so that evaluation and treatment can begin immediately before they are transferred to an inpatient bed, adds Mow.

Administrators came up with the concept for PACE when they observed that the needs of patients coming to the ED for care were changing. "Over the last 18 to 24 months, the acuity of patients has continued to rise, really eliminating the need for us to have a fast-track area," says Mow. Instead, what the health system needed was a place to deliver a higher level of care, which is what PACE is equipped to deliver, she says. "We are sending 35% to 40% of our patients over to the PACE unit over the course of the day," adds Mow. (Also, see "The case for creating rather than building capacity", below.)

First, establish optimal work flow

The PACE unit is hardly the first care delivery innovation to come out of VMMC. Applying the Toyota production system to health care, the health system established its own Virginia Mason Production System, or VMPS, that it now uses to develop all of its processes. "Our role is always to design the work and the most efficient flow, and then design the facility to support the work as opposed to a lot of other models where people build a building, they are handed a set of blueprints, and then they kind of shoe-horn the work into it," explains John Gillespie, a VMMC spokesman. "The new ED is in an addition to the hospital called the Jones Pavilion that is literally being designed and built a floor at a time to support the ideal flow for the activities that will occur on that floor."

When planning for the new ED began about three years ago, developers focused on what would be the most efficient and cost-effective way to take care of a patient with the best-quality outcome, says Gillespie, noting that they looked at the entire continuum of the ED experience. "That is where the concept of PACE came from, understanding that so many of the patients who come into the ED environment are not acute patients," he says. "The latest data we saw here is that the average delay or wait in an urban ED is six hours right now. That is because you have people who are not acutely ill taking up those acute beds."

The waiting room in the ED tends to be pretty empty, says Mow. During peak hours there may be a few patients or some family members who are in the waiting area, but that is not the norm, she says. "We triage at the bedside so our patients are greeted and immediately brought back to a bed, versus the typical type of triage where patients are triaged out in the waiting area or a triage room, and then they wait to see a provider," says Mow.

All patients are initially admitted to the ED and seen by the ED team, says Mow. "We do what we call a 'team greet,' so our ED providers, nursing staff, and patient care staff are all at the bedside," she says. "There is one type of report, they all hear what is going on, and care is initiated."

The PACE team includes a separate set of nursing staff who will come over to the ED, get bedside reports from the ED nurses, and discuss any questions with patients as they are transitioning their care over, explains Mow. However, what provider will oversee a patient's care in the PACE unit will vary depending the patient's status. Patients who are going to be admitted to the hospital or are going to be on observation will be transferred from the ED provider to a hospitalist team right away, adds Mow. "Those patients who we think will be discharged and go home will stay under the care of the ED provider," she says. In either case, the approach frees up the ED for incoming patients.

An electronic tracking board keeps everyone informed about what the next step is for each patient: admission, observation, or discharge. "The PACE unit charge nurses are watching that board, and once they see 'observation status' go up, they will call over to the ED to see if the patient is ready to come over," says Mow.

Patients typically stay in the PACE unit for 4 to 48 hours, depending on what their care needs are, adds Mow. "If they become sicker or they meet inpatient criteria, then we will look for a bed on an inpatient unit."

Consider long-term benefits

At press time, early data regarding patient satisfaction with the new ED/PACE unit approach were still being tabulated, but Mow says the concept has been well-received by hospital staff. For example, she explains that nurses are pleased that the approach has eliminated the prospect of having to move patients into the hallway while awaiting care. "From a nursing perspective, they know these patients will be passed off to another care team, that they will be well cared for, and that they are going to get what they need," says Mow.

The hospitalist team appreciates having their patients consolidated in one particular area, with nursing staff rounding very frequently so that patients are discharged on a continual basis throughout the day, as opposed to once or twice a day, adds Mow.

The PACE unit concept was a tougher sell to the ED providers when it was in the discussion stage because they were concerned about moving some of their patients across the hall, as opposed to having direct line of sight, observes Mow. However, they have come to appreciate the ability to focus on acute patients in the ED. "They saw that advantage right away, so this has been a great transition for all of us," she says.

The hospital has further plans to leverage the PACE unit in the coming months. For example, transplant patients, who have traditionally been admitted through the ED and processed as they are prepared for their organ, will eventually go directly to the PACE unit, says Mow. Also, some of the direct-admission patients will go directly to the PACE unit, thereby freeing up more space in the ED. "We will have hospitalists come down and see the patients there, get their orders initiated, and all of the initial testing will be done so that the stay is compacted and LOS is reduced," says Mow. "We are working out the process for that."

There is no denying the expense involved with building a new ED. And VMMC's new facility came in at a tab of $8 million, with a few hundred thousand more going toward the PACE unit, says Gillespie.

"What you are seeing nationally is a boom-town effect in a lot of places where people are just building EDs, building rooms, and spending a ton of money, but they are not looking at the process or the flow," he says. Ultimately, Gillespie believes that the benefits of the ED/PACE concept will cascade throughout the health care system and more broadly into the community. "We are a non-profit, so every dollar we use is a community resource," he says.


The case for creating rather than building capacity

Why is the patient acuity level rising at so many urban, hospital-based EDs? In Seattle, WA, part of the reason is because the market is flooded with resources to handle the less acute problems, observes Sharon Mow, MSN, the ED director. "There are a lot of free-standing EDs, and many, many urgent care centers in the immediate area," she says. "So a lot of the bumps, bruises, and sprains are going to those facilities and we're seeing those who are more acutely ill heading toward hospital-based EDs."

Another factor is the high level of homelessness in the Seattle region, explains John Gillespie, a Virginia Mason Medical Center (VMMC) spokesman. "This area tends to be a magnet for the homeless because there are a lot of services and it has a more temperate winter climate than other northern areas of the state," he says. Further, Gillespie points out that VMMC is a multi-state, quaternary care system, so the acuity level of patients is going to be a little higher.

"All of these things come together, so you have this potion or witch's brew of circumstances driving up acuity," he says. "And as an organization, you can do one of two things: you can build a whole lot of capacity or you can create capacity by providing better, more efficient care. We have created capacity."

For example, even while demand for services has surged, VMMC has reduced the amount of square footage being used to care for a patient, says Gillespie. "We have removed more than 26 miles of walking for our staff in a day by making processes more efficient," he says. "All of that plays into how we deliver better emergency care."