Posted February 01, 2014

Three Best Practice Models for Driving Efficient Flow

By Stephanie Baker, R.N., MBA, CEN Regina Shupe Dan Smith, M.D., FACEP

Improving flow in the emergency department ensures our patients receive safe, quality care and have better experiences. When ED’s flow is inefficient, we lose the ability to provide treatment in a timely manner, wait times are longer and we see an increase in sentinel events. Ultimately, flow inefficiencies prevent us from achieving and sustaining excellence.

Looking ahead to fourth quarter 2015, Centers for Medicare & Medicaid Services (CMS) will likely tie emergency department throughput/quality measures to reimbursement. Data is already being collected and reported publically for measures including door to admit, door to discharge, and time from admit decision to departure. As ED caregivers, the time to act is now. There are several tools for diagnosing and treating flow issues that are outlined below. We at Studer Group recommend diagnosing the challenges before trying to treat them.

One of the key ways we suggest to diagnose flow challenges includes asking questions that identify issues with front-end flow (door to bed), middle flow (bed to disposition), and back-end flow (disposition to discharge or admit). Sample questions can be found here. In addition, a dashboard can help track what’s working well and opportunities for improvement. The dashboards should then be reviewed during staff huddles and key meetings.

It’s equally important to review and manage demand-capacity and ensure the correct processes and communication tools are in place. By tracking patient arrivals (demand) and comparing it to provider capacity, we can better manage demand-capacity, ensure better flow and decrease wait times.

After the type of flow challenge has been identified and data has been reviewed, there are several ways to improve flow in the emergency department. Three of those best practice models include provider-in-triage, super-track and split-flow.

  1. The provider-in-triage method is just that; placing a provider in the triage area to quickly examine and treat low-acuity patients. This model is particularly effective in emergency departments with high numbers of left without being seen (LWBS) patients who are considered low-acuity (ESI 4 to 5), and those with high daily volume. The only requirements for this model include a small, private workspace, basic tools and a nurse to work with the provider to treat patients. After assessing the patient, the provider can then write a prescription and discharge the patient, or divert them back to the reception area if their assessment determines other factors that require further testing or treatment.

  2. The super-track model is ideal for emergency departments that also have high daily volumes and LWBS patients, but whose patients are low-to-middle acuity (ESI vertical 3, 4, or 5) with prolonged length of stay. This method works well in ED’s where you know the times you see a surge in patients. Then you can have essential services and dedicated staff, such as radiology and laboratory testing. This allows the mid-level acuity patients to be tested and treated more quickly, which in turn reduces length of stay and improves throughput metrics. A dedicated care area, nurse, physician/mid-level provider and typical fast-track equipment is necessary to successfully implement the super-track model.

  3. Emergency departments that experience excessive length of stay, high percentages of LWBS and have opportunities for improvement across all acuity levels (ESI 2 to 5) can benefit from the split-flow model. Patients are seen by a nurse who performs an initial assessment to assign acuity level. The charge nurse or “flow coordinator” then assigns a care space in the ED and the patient is registered. The key here is to keep vertical patients vertical to promote bed turns and decompress the ED. Triage nurses can then place patients in the rapid-treatment area (ESI vertical 3, 4 & 5) or the core area (ESI 1, 2 and horizontal 3). A second assessment is performed and the medication reconciliation form is completed by a nurse. The provider performs the examination, orders initial lab assessments, medications and so on, and then patients are moved to the results-pending area.

    The results-pending area is not a waiting area, but a place where patients can receive medications and wait for lab results. This area should be staffed with a nurse to ensure safety. Results-pending areas improve the ED’s ability to see new patients more quickly and allows for more efficient bed turnover. This model has worked particularly well for an organization coached by Studer Group, John Peter Smith (JPS) Health Network, who saw a 35 percent improvement in LWBS patients and patients who left against medical advice over a 10 month timeframe. In fact, some days the vertical pathway of the split-flow model processes 60 percent of their patients.

While each of these models can have a significant effect on cycle times and throughput intervals, bed capacity issues can inhibit their full impact. Implementing flow teams and ensuring the full engagement of physicians, managers, and leaders is of the utmost importance. “Boarding” of patients is one of the main issues in emergency departments and ultimately impacts the service and quality of care patients receive. Once the best model for your organization is chosen, it’s vital that all staff are committed and driven to hardwire the model and remain consistent. When flow in the emergency department is addressed, those best practices can be implemented to improve organization-wide flow too.

Additional Resources:

Baker, S., Smith, D., Shupe, R. Driving Efficient Flow: Three Best-Practice Models.. J Emerg Nurs. 2013; 39 (5): 481-4.

About the Authors:
Stephanie Baker, RN, MBA, CEN, is a Coach, Account Leader, and National Speaker with Studer Group. She has over 25 years of clinical nursing and administrative experience in the areas of Emergency, Trauma, Flight, and Critical Care medicine and proven results with her partners around the country. She is a national speaker and presenter at Studer Conferences

Regina Shupe, RN, MSN, CEN, is a Coach and National Speaker with Studer Group. With over 25 years of administrative and clinical nursing experience, that includes Emergency, Trauma, and Critical Care; Regina has driven ED results in both the large academic setting as well as small rural settings.

With over 15 years of experience as a practicing physician, Dan Smith, MD, FACEP provides coaching to organizations through his work with Studer Group. He is also a national speaker and presenter at Studer Conferences


  • Stephanie Baker

    Stephanie Baker, R.N., MBA, CEN

  • Regina Shupe

    Regina Shupe

  • Dan Smith

    Dan Smith, M.D., FACEP

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