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Super TrackThe Evolution of the Split Flow Emergency Department
John D’Angelo, MD, FACEPNorthwell Health
Robert Masters, AIA, NCARB, LEED APCannonDesign
2
Agenda
1. Emergency Department Flow
2. Evolution of the Super Track Model at Northwell Health
3. Case Studies: Flow Meets Design
a. Southside Hospital
b. Huntington Hospital
3
Learning Objectives
1. The value of the Super Track split-flow organizational approach in emergency departments as an effective lean process re-design strategy.
2. The implications of the Super Track approach on the planning and design of emergency departments, both for renovations and new construction.
3. Examples of how design can impact throughput and average length-of-stay in the emergency department.
4. Strategies that enhance design team and medical team collaboration for better operational and clinical outcomes.
Northwell Health Emergency Medicine Service Line
4
Emergency Medicine Service Line
• 5 Tertiary Emergency Departments
• 11 Community Emergency Departments
• 2 Affiliate Tertiary Emergency Departments
• 1 Free-Standing Emergency Departments
• 33 Northwell Health-Go Health Urgent Care Centers
• CVS Minute Clinic Partnership
Clinical Operations
• ~ 900,000 Annual Emergency Department Visits
• >70% of all system inpatient admissions via Emergency Departments
Volume
• Over 340 Full Time/Part Time Physicians (plus another 215 Per-Diem)
• Non Physician Staff ~1,600 FTEs
Workforce
5
Emergency Department Flow
6
Emergency Service Work Flow
“And this is where our ED workflow redesign team went insane.”
“Every System is Perfectly Designed to Achieve the
Results it Achieves”
7
What’s new since most of todays ED’s were built?
Lean Process Re-design:
• Split flow, super tracks, team triage
• Vertical patients, “not every patient needs a room”
• Greater scrutiny on clinical coverage (cost and availability)
Regulatory:
• CMS reporting requirements (LOS, door to X measures)
• P4P
IT:
• EMR, Tracking boards, WOWs, CPOE, biometrics, RTLS, telemedicine
• Consumer focus - At home check in apps, no wait EDs, entertainment options
• Registration Kiosk, tablets, Prescription Kiosk – delivery services
• Real time dashboards
8
Population Health / Payer Influence
• Management of frequent utilizers
• Shift of lower acuity patients out to alternative providers (PCPs, UCCs, Retail)
Consumerism:
• Wait time apps and billboards
• Alternative choices: FSEDs, UCCs, Retail
• Patients Satisfaction P4P
Medical Advances and Trends
• Radiology – CT, MRI, Bedside US
• Telemedicine, E-ICU
• Observation Medicine
• Specialty EDs or design components:
Geriatrics, Pediatrics, Cancer, Bariatric
Surge, Infection control (Ebola like processes)
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What’s not new?
Rising Volumes
Hospital Closings
Shrinking inpatient capacity
Rising Acuities
Increase in Behavioral Health issues
Tight staffing
Budgetary constraints
And so on...
The Case for Workflow Redesign
Source: Studer Group and CEP
Improved:
• Patient Satisfaction
• Staff Satisfaction
• Quality of Care
• Reduce Risk
• Department Capacity
• Finances
10
IMPROVE CAPACITY!!!
Throughput: “Typical” ED Flow
There are essentially three components to a patient’s visit to the ED
INPUTPatient arrives
THROUGHPUTStuff happens
OUTPUTPatient leaves
Complex Processes Plagued By Bottlenecks
11
• Parallel rather than sequential processes
• Direct to bed / treatment area
• Triage bypass / Short Triage
• Quick Registration
• Bedside Registration
• Provider in Triage
• Team Triage
• Super Track / Split Flow
Input: Door to Provider (MD or MLP)
Eliminating Bottleneck & Delays
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• Align the rest of the organization with ED success
• Lab and Rad Turn Around Time (TAT)
• Super Track
• Results Waiting Area / Sub-waiting / other servers
• Keep vertical patients vertical
Throughput: Provider to Disposition
• Improve Admission process – Greatest Challenge and Impact on capacity, throughput and patient safety in most EDs
• Set goals and organize people around them
Output: Disposition Decision to Departure
Eliminating Bottleneck & Delays
13
Process:
The Split Flow process is an evidenced based principle of bed conservation where resources are matched with patient flow in order to alter the care process.
The Split Flow Process
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• Replace Triage with “Quick Look” Clinical Assessment for Incoming Patients
• Split Patient Flow
• Vertical/low acuity patients don’t own beds – rapid treatment
• Capacity to meet volume using queuing analyses
Banner Health new ED model for patient flow (2006)
• Rapid triage of each patient by clinical team
• Accelerated treatment (lower acuity patient)
• Quicker admission (higher acuity patient)
• Eight EDs adapted to the two-track patient flow model
The Development of the Split Flow Model
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1. Faster time to treatment: reduced by 58%
2. Fewer walk-out patients: reduced from 7.1% to 1.7%
3. Reduced ED length of stay: reduced by 14%
4. Enhanced capacity to serve patients: increased by 1%
Triage (verb)
Brief RN Assessment ESI Level / Acuity
Low AcuityPathway
ESI Levels 4, 5, some 3’s
Moderate AcuityPathway
Most ESILevel 3’s
High AcuityPathway
ESI Levels1 and 2
~ 30-40% ~ 50-60% ~ 10%
Matching Our Service Delivery to our Incoming Patient Stream
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Does every patient require a bed?
Increase Capacity: Add Space
Vertical Patients
• Ambulatory
• Well / Low Acuity
• Younger
• Perceived Urgency or Convenience Driven
• Value (Starbucks)
• Speed
• Convenience
• Other non-medical factors
Horizontal Patients
• Arrive by Ambulance
• Sick / High Acuity
• Older
• Serious or Life Threatening Condition (real or perceived)
• Value (Traditional Healthcare)
• Safety
• Preserve Life or Limb
What about a chair?
17
Parallel vs. Sequential Front End Process
Pt. Arrives
“Quick Look”Triage
Quick Reg
RN / Provider / Tech Team
Main ED
DischargeArea
Testing Station
Results Waiting
Area
Rx / Minor
Procedures
Super Track
18
Summary: Potential Super Track Advantages
1. Reduce square footage requirements from traditional ED concept
2. More efficient throughput and reduced ALOS
3. Keep vertical patients vertical
4. Separate lower acuity patients from higher acuity level patients
19
Evolution of the Super Track Model at Northwell Health
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Long Island Jewish Medical Center
ED Modernization – 2006
• 21,000 sq. ft. clinical addition
• Comprehensive, multi-phased renovation
• Critical Care, private treatment rooms, Imaging, Behavioral Health, Pediatrics
LSGS Architects/Perkins Eastman LSGS Architects/Perkins Eastman
21
Long Island Jewish Medical Center: Adult ED Volume
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20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
110,000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016Projected
2017Projected
Adult ED Volume Trends
Adult ED Volume Split Flow Capacity Current Capacity
Long Island Jewish Medical Center: Door to Provider Time
23
20
40
60
80
100
120
140
Door to Provider Time
Change Implemented
Door to Doc
Mean
UCL
LCL
Long Island Jewish Medical Center: Treat & Release LOS
24
240
260
280
300
320
340
360
380
400
Treat and Release LOS
Change Implemented
T&R LOS
Mean
UCL
LCL
Long Island Jewish Medical Center: LWOBEs
25
0
0.01
0.02
0.03
0.04
0.05
0.06
LWOBE Percentage
Change Implemented
LWOBE
Mean
UCL
LCL
Long Island Jewish Medical Center: Likelihood to Recommend
26
30
35
40
45
50
55
60
65
70
75
Likelihood to Recommend (Top-Box)
Change Implemented
LTR
Mean
UCL
LCL
Long Island Jewish Medical Center
27
Adult ED Split Flow Floor Layout
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Pre Improvement Statistical Analysis of
Door to Doctor LOS –March 2016
Sigma Score 1.2, mean time 94 mins.
Post Improvement Quid 16 hours/7 days
Door to Doctor LOS –September 2016
Sigma Score 1.8, mean time 68.5 mins.
Long Island Jewish Medical Center
102
68
Jan. Sept.
Door to Provider
33% Decrease
3.9
2.1
Jan. Sept.
LWOBE
93,964
98,820
2015 2016
Volume
358
302
Jan. Sept.
T&R LOS
16% Decrease
5% Increase 47% Decrease
Lenox Hill Emergency Department:
• Sees nearly 56,000 patients.
• The new space (south side) had a larger footprint, added privacy, multipurpose rooms, and replaced most stretcher spaces with recliner chairs.
Lenox Hill Hospital
29
30
NORTH SIDE
SOUTH SIDE
Lenox Hill Hospital
Design
FT
Lenox Hill Hospital
New South Side design
• Chairs replace most stretchers
• New Omnicell
• New curtains
• Procedure room
• Adjacent to X-ray
Lenox Hill Hospital: Door to Provider Time
32
0
5
10
15
20
25
30
35
40
45
50
Door to Provider Time
Change Implemented
Door to Doc
Mean
UCL
LCL
Lenox Hill Hospital: Treat & Release LOS
33
150
170
190
210
230
250
270
Treat and Release LOS
Change Implemented
T&R LOS
Mean
UCL
LCL
Lenox Hill Hospital: LWOBEs
34
-0.005
0
0.005
0.01
0.015
0.02
0.025
LWOBE Percentage
Change Implemented
LWOBE
Mean
UCL
LCL
Long Island Jewish Medical Center: Likelihood to Recommend
35
30
40
50
60
70
80
90
Likelihood to Recommend (Top-Box)
Change Implemented
LTR
Mean
UCL
LCL
Flow meets Design!
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Boston
NYC
DC
Phoenix
Los Angeles
Chicago
Buffalo
Baltimore
St. Louis
Vancouver
Toronto
San Francisco
Shanghai
Mumbai
Montreal
Pittsburgh
Our single-firm, multi-office approach offers our clients access to full resources from offices worldwide
• 100 years of legacy
• 16 offices with over 900 personnel
• 550 health care staff
• Single firm, multi-office (SFMO) approach
• 3rd largest practice in the world in volume
• Top 5 ranked healthcare practice for past 20 years
• Fully-integrated Architecture / Engineering / Planning / Interiors / Cost Estimating / Facility Optimization
• In-house Operations, Clinical, and Research capabilities
Who is CannonDesign?
Fixed x-ray unit located adjacent to triage accelerates plain film imaging for walk-in patients
Super Track Model Differentiator
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Placing a physician at triage substantially expedites Arrival-to-Physician evaluation times
Super Track Model Differentiator
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Southside HospitalExisting Emergency Department:
• Area: 11,000 square feet
• Construction: mid-1970s• 22 Treatment Bays• Original volume: 30,000 visits
• Modular addition: 2007• (9 Fast Track Bays)• 56,000 visits• 1 bed : 1,800 visits
• Project Kick Off 2013 • 71,000 visits• 1 bed: 2300 visits
• 2021 projections• 90,000 visits
Existing Emergency Department
Walk-In EntranceAmbulance Entrance
40
Current State:
•2013 Volume = 70,634 visits
• Admission rate – 16%
•Current department has 33 beds
•Traditional ED capacity model 1 bed for every 1300 patients / yr
• Current volume 70,634 visits / 1300* = ~ 54 beds
• Projected 2021 volume 87,769 visits / 1300* = ~ 68 beds (~55,000+ sq ft)
Southside Hospital
Problem: Volume exceeds capacity!
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Problem: Volume exceeds capacity
How do you increase capacity?
- Add space, i.e. treatment units (ex. beds)
- Improve throughput / decrease LOS
Recommendation: Do both!
Southside Hospital
Solution: Increase Capacity!
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ED Expansion Design:
• Infill addition
• Expansion into Brackett Pavilion to the west
• New walk-in entrance on the south of the ED
• Dedicated Super Track
• Results Waiting
• Dedicated Behavioral Health Evaluation Area
• Targeted renovations in the existing ED:
• Expanded Trauma & Critical Care
• Expanded Imaging
• Expanded IsolationWalk-In Entrance
Ambulance Entrance
Behavioral Health
Entrance
Southside Hospital
43
Southside Hospital
Gradient of Care:
• Concentrating low acuity care at the walk-in entry
• Higher acuity & specialty care radiates from the Super Track hub
• Critical Care Corridor and Isolation Suite developed off of Ambulance entry
1
2
3
4
5
ESI LEVEL
Walk-In Entrance
Ambulance Entrance
BehavioralHealthEntrance
44
Super Track ED:
• Clinical greeter
• Intake Rooms
• Super Track bays
• Super Track rooms
• Flexible to Urgent
• Results Waiting
• Low acuity X-Ray Room
• Sub-wait
45
1
1
2
2
3
4
3
4
5
5
66
7
7
Southside Hospital
Super Track ED: Clinical GreeterSuper Track ED: Low-Acuity Treatment BaysSuper Track ED: Results Waiting for the Vertical PatientSuper Track ED: Low-Acuity Sub-Waiting
Southside Hospital
Phase 2 ED Expansion:
• Renovating the balance of the existing ED
• Rightsizing support space for Critical Care
• Expanding Emergent Pod to the south
• Flexible Pediatrics area
• 16-bed Observation Unit
46
Phase 1B ED Expansion:
• Isolation Suite
• Resuscitation Rooms
• Trauma Room
• Critical Care Imaging
• 16-bed Observation Unit
• Town Hall Meetings
• Share designs and plans with frontline staff; discuss new split flow model
• Respond to staff questions
• Staffing adjustment
• New workflows require changes to the staffing ratios
• Staff Simulation / Training
• Space and workflow walkthrough for staff followed by simulating their new workflows with volunteers as patients
Go Live Preparation
Southside Hospital: Door to Provider Time
48
0
20
40
60
80
100
120
Door to Provider Time
Change implemented
Door to Doc
Mean
UCL
LCL
Southside Hospital: Treat & Release LOS
49
150
200
250
300
350
400
Treat and Release LOS
Change implemented
T&R LOS
Mean
UCL
LCL
Southside Hospital: LWOBEs
50
-0.01
2E-17
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
LWOBE Percentage
Change implemented
LWOBE
Mean
UCL
LCL
Southside Hospital: Likelihood to Recommend
51
0
10
20
30
40
50
60
70
80
90
Likelihood to Recommend (Top-Box)
Change implemented
LTR
Mean
LCL
LCL
Huntington Hospital
Existing Emergency Department:
• Construction: 1983
• Area: 14,400 DGSF
• Current treatment beds: 36 Existing Treatment Positions
• Existing volume: 52,000 visits
• 1 Bed for every 1450 visits
52
Current State
Huntington Hospital
How many Main ED Beds are needed for Moderate to High Acuity?ESI
AcuityTotal Percent total
1 62 0.4%
2 993 6.2%
3 8464 52.6%
4 6200 38.5%
5 367 2.3%
50 % of all Patients????
= ESI 1’s, 2’s, 80 % of 3’s
= ~ 32,500 visits
= ~ 27 beds based on 1:1200 ratio
= ~ 32 beds based on 1:1000 ratio
33 % of all Patients????
= ESI 1’s, 2’s, 50 % of 3’s
= ~ 21,500 visits
= ~ 18 beds based on 1:1200 ratio
= ~ 21 beds based on 1:1000 ratio
53
Huntington Hospital
ED Renovation Design:
• Addition and partial renovation of existing administrative space
• Dedicated Super Track
• Results Waiting
• New Imaging area
Ambulance Entrance
Walk-In Entrance
54
Huntington Hospital
Gradient of Care:
• Concentrating low acuity care at the walk-in entry
• Higher acuity & specialty care radiates from the Super Track hub
• Public corridor separates lower and higher acuity patients
55
Super Track ED:
Clinical Greeter
Intake Rooms
Super Track bays
Super Track rooms
Results Waiting
2 X-Ray Rooms and 1 CT Scan Room
Huntington Hospital
56
1
2
3
4
5
6
1
2
3
4
5
6
Construction Progress: Clinical GreeterConstruction Progress: Intake RoomsConstruction Progress: Results WaitingConstruction Progress: Super Track Bays
Huntington Hospital
Results Waiting
Results Waiting in Super Track:
57
• The solution to your efficiency needs is not always a bricks & mortar solution
• Don’t be afraid to be innovative with your design concepts
• When you are considering a design or re-design:
• Optimize flow• Focus on process engineering• Use improvement science-driven
implementation and iteration• Leverage technology to meet your needs
• Interdisciplinary collaboration will lead to a stronger solution
Key Takeaways
58
Super TrackThe Evolution of the Split Flow Emergency Department
Presented by:
John D’Angelo, MD, FACEP, Northwell Health
Robert Masters, AIA, NCARB, LEED AP, CannonDesign
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