New ED intake system at UK HealthCare creates vital changes

By Mallory Olson

Dr. Daniel Moore photographed for a story on his new intake system in the ED on October 17, 2019. Photo by Pete Comparoni | UKphoto

Overcrowded emergency rooms are a problem plaguing hospitals nationwide. In an environment where every second counts, intervention is needed to reduce wait times and improve patient safety. UK HealthCare is taking the lead nationally to effect change.

According to the Centers for Disease Control and Prevention, nearly 146 million Americans visited an emergency room in 2016. A third of them spent between two and four hours in the emergency department (ED). In some cases, patients give up and leave before seeing a doctor.

“’Emergency’ and ‘wait’ are two words that cannot go together,” said J. Daniel Moore, MD, an associate professor in the Department of Emergency Medicine at the University of Kentucky. “We should not be bringing patients back who are even more sick than they were when they walked through the doors just because they had to sit and wait for an exorbitant amount of time.”

Moore is part of a team at UK HealthCare that has developed a new way to route patients through the system efficiently, implementing a mixture of novel and evidence-based solutions that other institutions have successfully deployed. It has nearly eliminated the number of patients who leave the ED without being seen and is drastically improving patient access to the care they need.


Designing Wait Out of the System

If you walk into the waiting room of the UK Chandler ED today, it’s rare to see more than half a dozen people waiting for care. A few short years ago, the place looked like a busy bus terminal with dozens of crowded people waiting to see a doctor.

The UK HealthCare adult and pediatric ED’s at UK Chandler Hospital have about 90,000 emergency department visits each year with an average of 250 patients every day. Between Chandler and UK Good Samaritan Hospital, UK HealthCare has the busiest ED in the state and among the top 25 percent in the country.

Moore recognized the need for change and worked to implement a redesign of front-end processes, using the department’s own data.

“We were able to predict exactly how many patients per hour were arriving and exactly what resources were needed to match that demand,” he said.

It didn’t take long to see improvements: from the moment patients walk through the door these days, it takes about 27 minutes for them to see a doctor at UK Chandler Hospital. Before the new intake system, the average wait time was more than twice that and even worse during the evening, which is the busiest time of day for emergency departments.

“Since implementing this system we are more efficiently able to identify patients who are safe to go home, creating five million additional minutes per year of functional capacity to treat the sickest patients. That’s huge,” Moore said.

The UK Chandler ED is the one of the first academic hospitals in the country to achieve this level of success.

Moore is seeing an improvement in patient safety as well. Some patients without a family doctor use the ED for their medical needs, which slows the intake system down. Combined with longer lobby wait times, this meant some very sick patients were lost in the crowd and couldn’t get the help they needed fast enough. Today, every patient who walks through the door is seen by a nurse during registration and an attending physician within minutes. If they need immediate care, it’s recognized, and they get it.

The most dramatic change is in the number of patients who leave the ED without being seen.

The national benchmark for the percentage of patients who leave before seeing a doctor is two percent, although the norm is about three percent. UK was running in the 3.5 percent to four percent range before establishing the new patient intake system. Now the hospital is a national best performer with less than 0.3 percent of patients leaving the emergency department without being seen.

How It Works

Moore’s approach is called a Physician Intake Pod with Vertical Split Flow (PIP-VSF). This system requires a front-end team: a pivot nurse, an attending physician, a scribe, two triage nurses, two paramedics and a nursing care tech.

There is also a “vertical treatment space” staffed with two advanced practice providers (APPs), two nurses and a nursing care tech.

Patients are put into the system soon after they walk into the ED. The first person you’ll interact with is a pivot nurse.

That helps get the patient back to a doctor faster. Patients brought in by ambulance get their vitals checked and are assigned an acuity level from one to five. The most critical patients are sent straight back for treatment. Patients who are less critical are enter PIP-VSF.

There are two triage rooms in the UK Chandler ED. A registered nurse and doctor assess the patient together before the doctor decides if the patient needs to lie down (horizontal), can stay seated (vertical) or can be discharged. The nurse simultaneously places any orders for bloodwork, radiology and therapeutic interventions while the scribe generates a chart. As a result, a physician can screen up to 10 patients per hour, which is five times greater than the normal productivity of an emergency physician.

-Mallory Olson is with the department of public relations and marketing at the University of Kentucky.