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Tales From The Administrator: ED Flow Part 1: Triage

Sam Ashoo, MD
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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EM:RAP 2015 October Summary 928 KB - PDF

Triage is a process, not a location!

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Mark J., M.D. -

Sam

I think there are a couple nuances you mention that would be a benefit to expound on a bit

1) Neither push nor pull works in a system with uneven demand like the ED, but either push or pull can work in certain circumstances. Push only works when there is a space AND staff available to care for the patient. So often 'pull to full' (which is in practice push) disregards the need for both and, if there is no staff available only leads to overburden and unsafe care as the patient is placed somewhere with no one capable to monitor them while they wait. Pull only works when there is an over all strategy embraced by everyone that promotes flow. Too often, we each work in the silo of our individual tasks and lose sight of the goal of flow.

2) Although it is often talked about as input, throughput and output- flow is an output issue. Think about a funnel- pour enough water in and it overflows no matter what you do to pour more in faster or slower. But turn the funnel over and pour with the spout up? never overflows. It would be better, I think, to start with output because everything we do at input and throughput should support this.

3) Increasing capacity should be the goal ( not necessarily beds which is what the ACEP report you reference suggests)- but meaning to have staff and space to handle the next arriving patient

4) This would lead to a dept strategy that divides the ED's day into 3 scenarios as you describe 1) no patients; 2) some but still not everyone occupied; 3) everyone occupied (this might occur without every space occupied if there are resuscitations taking the attention of multiple people)

5) in 3), this requires an overload strategy that once identified moves the ED back to a situation of capacity to handle the next arriving patient. This has been studied in small to medium volume ED's (10-25,000) and most ED's have periods of large influxes, but then followed by a period of less or fewer and this is usually on around a 3 hour cycle, meaning if you can get caught up in that time, you are ready for the next influx. If not, the subsequent influxes ladder on top of the remaining patients and by late in the day, there is hopeless gridlock. What happens at 10am determines what happens at 6 pm.

6) In larger ED's these cycles are overwhelmed and if a place has this sort of gridlock every day, they are just too much under-resourced or have processes that are just too cumbersome to keep up. No amount of input management will solve this, ie the overflowing funnel, but throughput maneuvers can help. If everyone in and out of the ED is focused on having a space and staff to see the next arriving patient, then there is an over all institutional view that supports flow-- a tough thing to achieve that shared outcome, but without which we and our patients just suffer. My experience is that apporached this way, it is not as tough a sell as it might seem, but we can talk about that more

7) Provider at triage and fast track are really output strategies

8) The point is, I think, flow in a system with so many moving parts is quite complex, but without a direction that can serve everyone's interests, no amount of tinkering will achieve the desired results. Implying otherwise will just lead to frustration, poor experiences, and despair at trying to improve anything

I look forward to your impressions. I suspect you recorded your pieces long ago, and it is good stuf. Thanks

Mark Jaben, MD

Rhone D. -

Great segment and great comments above by Dr. Jaben. We aggressively use flow nurses and APPs (MLPs) in triage, fast track, and main ED to keep patients moving through and to rapidly (and safely) dispo low acuity patients and those who are fully resulted. It's a constant battle with full lobbies but we have success with this and good patient feedback as well.

Sam Ashoo, MD -

It has been sometime since this recording but if any of you are still interested in patient flow, I've started a new project here: https://admin-em.com/patient-flow/

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Vents, Scabies, and IV Fluid Cage Match Full episode audio for MD edition 256:28 min - 357 MB - M4AEM:RAP 2015 Octobre Résumé en Francais Français 65:06 min - 39 MB - MP3EM:RAP 2015 October Aussie Edition Australian 31:30 min - 43 MB - MP3EM:RAP 2015 Octubre Español 71:43 min - 38 MB - MP3EM:RAP 2015 October Canadian Edition Canadian 20:46 min - 16 MB - MP3EM:RAP 2015 Español Octubre 2015 1 MB - PDFEM:RAP 2015 October Board Review Answers 243 KB - PDFEM:RAP 2015 October Board Review Questions 343 KB - PDFEM:RAP 2015 October MP3 253 MB - ZIPEM:RAP 2015 October Summary 928 KB - PDF

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