In the past, patients with minor conditions such as ear pain or a sinus infection might have found themselves waiting for hours in a crowded emergency department (ED) waiting room, growing more frustrated as they watched more seriously ill patients receive attention more promptly.
Sentara RMH Medical Center has taken steps to help prevent that type of situation with its newly redesigned ED, which separates acute patients from those who are considered to be nonacute (generally defined as patients who do not require constant monitoring and who are likely to be discharged quickly). With the recent changes, these two groups of patients no longer will be competing for the same bed space.
“In the past, sometimes we’d have numerous patients in the waiting room, on top of a full department and overflow unit,” says Brandy Sollenberger, clinical nurse manager for the ED at Sentara RMH. “In those cases, some patients might have had to wait six to eight hours, which was far from ideal.”
The redesign, which began in July 2019, is based on the concept of vertical care—also known as focused care—which helps streamline patient flow through the ED with a different physical setup and a new set of procedures. The goal of the new system is to release nonacute vertical care patients within two hours, and admit acute care patients to the hospital, if needed, within four hours.
Before the vertical care system was fully implemented at Sentara RMH, the median time patients spent in the ED from check-in to departure was three hours. Following the redesign, that time has dropped by more than 25%, to 2.2 hours.
How Does Vertical Care Work?
When entering the ED, all patients are now seen by an intake nurse, who asks them about their chief complaint, takes their pulse and oxygen saturation level, and decides whether the patient should go to vertical/focused care or acute care, according to Gina Yost, process improvement manager at Sentara RMH.
While patients are speaking to the intake nurse, which generally takes less than two minutes, they’re also being registered. Within 26 minutes of arrival, on average, vertical care patients are then brought back to a private exam room to speak with a care provider (physician, physician assistant or nurse practitioner) along with the intake nurse—another time-saving feature of the new process.
“We want patients to have to tell their story only once, not over and over to several different providers,” says Yost. “With the new parallel workflow, the patient only has to explain their symptoms one time.”
The provider will order imaging, labs or other tests, as needed, from the vertical care room. For patients with easily treatable illnesses, such as a sinus infection, the provider can order their prescriptions and discharge them right away, adds Sollenberger.
Another feature of the new system that helps save patients time is alluded to right in its name. To speed up care, vertical care patients literally stay vertical and don’t have to lie on a gurney or change into a hospital gown while waiting. Instead, they remain in street clothes. After seeing a provider, patients who require further testing may be taken to one of the eight recliners in the vertical care waiting room, where they are monitored by a team of nurses. For patient privacy, each recliner is separated from the others by a partition. Depending upon needed testing, the patient might also go to another small waiting room, where he or she would be called by a lab technician or imaging tech.
For sicker patients who may require more privacy, the vertical care area also includes four procedure rooms.
Improving Efficiency and Patient Care
For the past five years, Sentara has been working to increase ED efficiency systemwide. As part of that effort, according to Yost, Sentara staff visited Kaiser Permanente in California to learn about the “Kaiser model,” which is aimed at reducing length of stay and optimizing workflow in the ED.
Sentara Leigh Hospital in Norfolk was the first Sentara facility to implement the new model, followed by other hospitals in the Sentara system.
The changes began gradually at Sentara RMH, as staff worked under the new system guidelines while the supporting physical infrastructure was being constructed.
“When we were finally able to complete the renovation and move to the new vertical care area, we saw improvements almost instantly,” says Marcus Almarode, director of emergency and critical care at Sentara RMH. “Since then, the new system has greatly improved staff efficiency and the patient process.”
Although the new system can be a bit unfamiliar to patients at first, the intake nurse helps prevent any confusion by thoroughly explaining the process to newly arrived patients, Almarode says. Word of mouth from other patients also is helping to ease the transition.
“The days of long, inconvenient waits in the Sentara RMH ED are largely over,” adds Almarode. “Now, when patients are in the waiting room, they’re actually waiting for testing or lab results. In terms of getting patients the care they need in a timely manner, the new vertical care system has been a huge improvement for both patients and caregivers.”
What Separates Vertical Care from Acute Care?
Conditions considered for focused care:
•Ear pain without hearing loss
•Eye complaints without vision changes
•Skin conditions, such as eczema
•Strains, sprains and minor fractures
•Superficial burns, not including facial burns
•Upper respiratory infections without shortness of breath
•Urinary tract infections without fever or other pain
Generally, patients are eligible for vertical care if they are:
•Between the ages of three months and 75 years
•Can walk on their own and do not need a wheelchair to get back to the ED for treatment
Conditions referred to acute care include:
•Abnormal vital signs
•Cardiac conditions requiring monitoring