The Impact of a Mixed Fast-Track and Mid-Acuity Track Area With a Vertical Component on Emergency Department Throughput

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Conference Proceeding

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Annals of Emergency Medicine


Study Objectives: Fluctuations in staffing and patient volumes have stressed emergency department (ED) resources resulting in increased length of stay (LOS), increased door to doctor times for higher acuity patients, and increased left without being seen (LWBS) rates. Also, with the growing emergence of community urgent care centers, the need to staff a dedicated fast-track area in the ED has decreased. This study aimed to assess the impact of implementing a novel combined mid acuity track/fast track area with a vertical component that did not require additional department resources has on ED operations. Study Design: This was a retrospective before-after study examining the effect of implementation of a mixed fast-track and mid-acuity track at a large suburban, academic emergency department in a level 1 trauma center with a patient volume of about 110,000 in 2021. This area did not utilize additional ED resources but reallocated two nurses from other areas of the ED and was designed to operate on weekdays. A third nurse was added at noon to act as a flow captain; they obtained triage labs ordered by the physician in triage, completed triage assessments, and assisted with determining utilization of rooms and hallway spots. Following the initial triage process, patients with Emergency Severity Index (ESI) scores of 3 or 4 that were ambulatory or able to sit upright were selected for this area by a triage nurse or physician in triage. Patient selection was based upon high likelihood for discharge, not estimated resource utilization or LOS. Other patients with a higher probability for admission or those that could not remain vertical were seen elsewhere in the ED. The dedicated area had ten curtained rooms and four hallway spots in chairs. Some patients designated for this area remained in the waiting room awaiting results. Once placed in the area, patients were then evaluated by a senior resident or physician assistant to examine the patient and discuss results, treatment plans, and disposition. All patients were seen by an attending physician before discharge. The total LOS of discharged ESI 3 patients, door to provider time of ESI 2 patients, and LWBS to the main ED was measured in the 4-month periods before and after the intervention in 2022. Results: A total of 37,420 patients were seen in the four months prior to the implementation of the new mixed acuity tract and 35,591 were seen in the four months post implementation. The average LOS for discharged ESI 3 patients decreased from 352 to 301 minutes, a 14.5% decrease. The door to provider times for ESI 2 patients decreased from 89 to 54 minutes following implementation, a 39.3% decrease. The LWBS rate significantly decreased from an average of 6.2% to 2.3% (p





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