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Keeping Patients Vertical in the Emergency Department

Executive Summary

Emergency department (ED) overcrowding is a complex issue requiring multiple strategies to improve patient flow. Ambulatory patients are most efficiently handled in a vertical treatment room, a space that allows for the patient to remain in an upright posture. This room expedites specialists' ability to process various patient types by treating and releasing non-urgent patients, and by beginning treatment protocols on higher-acuity patients. Vertical treatment rooms require less space than conventional ED exam rooms. Questions addressed in this article include:
 
  • What is vertical treatment? 
  • Why go vertical?
  • Can waiting rooms really be eliminated?
  • How does one design a vertical ED?

 

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What is Vertical Treatment?

The premise behind vertical treatment is in facilitating patient throughput and satisfaction. These spaces are designed for short-term occupancy. If patients can forgo lying down unnecessarily, they are more likely to experience a shorter ED visit, which helps to increase the staff’s operational throughput and efficiency. Although clean and functional, vertical treatment spaces are not conducive to “camping out” for a leisurely stay. Accordingly, there may not be a TV, phone, or internet service, as well as chairs for visitors in a typical hospital room.

A key component to designing vertical treatment spaces is the ability to have a general sub-waiting space or results-waiting space that is both dedicated and adjacent. This sub-waiting space allows for the staging of non-urgent patients while they await test results or treatment to take effect. Clear lines of sight from the vertical treatment areas to the sub-waiting spaces allows for the clinical staff to maintain visual monitoring of all patients.

Often, emergency department overcrowding limits resource utilisation and quality of care as patients transition between hospital wards. The term “vertical patient flow” refers to the process of redesigning the front-facing operations of an ED to improve throughout and patient satisfaction. This process requires a high degree of political and collegial support in order to be implemented successfully.[1][2] Institutions with optimised vertical patient flow exhibit a number of similarities:

  • Patients bypass a waiting room and the traditional triage system;
  • Patients are assigned to a bed or exam room before completing registration; and
  • Patients are registered and triaged by a clinician in the exam room.

 

Why Go Vertical?

In addition to the above-noted benefits, the verticality policy also creates a mental and physical barrier between patients with marginal and critical conditions. Keeping non-urgent patients out of the acute care treatment spaces frees up much-needed capacity for when an acutely ill or injured patient arrives. However, recliner chairs can easily be made into stretchers if a patient's condition abruptly changes.

Patients spend less time waiting for services because clinicians can begin ordering diagnostic tests earlier.[3] As patients wait for test results and other resources to become available, they complete the registration process. The concept of change over involves switching from one process to the next to utilize resources more effectively. Having a clinician involved in the triage process as patients are being evaluated allows for rapid screening diagnosis and for clinicians to discharge minor complaints so that they never occupy an acute care bed. If the system allows for redundancy, patients may disrupt the flow, which may lead to resentment amongst the various professionals involved with caring for the patient and ultimately be counterproductive. This approach, if utilized effectively, is an effective means of keeping acute care beds available for those who truly need them.[3]


Can Waiting Rooms Really be Eliminated?

Some hospitals have taken the bold step to completely remove “waiting rooms” and in the process have created the illusion that all patients are seen immediately. In reality, it may be the case that patients are indeed seen faster; however, this can often deplete resources unnecessarily and be counterproductive, while creating the illusion that the system is more efficient. Increased infrastructure needs to be in place to absorb the ebbs and flows of patient load. By utilizing this approach, the bottom line of ED budgets can be severely impacted.[3] Ultimately, successful vertical patient flow will utilize several of the above approaches to decrease wait times and improve access to care. Is there a major commitment on the part of providers, nurses, administration, facilities, and the patients themselves? Patients have been conditioned to believe that long waits are inevitable in the ED setting; as such, clinicians and administrators will need to allay their suspicions. Ultimately, this will lead to better patient satisfaction scores, better provider satisfaction, and better patient care.[3]


Steps to Designing a Vertical Emergency Department

Step 1: Team Triage

  • Implement “rapid medical evaluation” or some form of team triage into the ED, so patient needs are immediately assessed by a care provider;
  • Patients that can be immediately treated will receive timely care and go home;
  • Patients that require further testing or procedures, but are still low acuity, can be sent to a “vertical space” to wait for results;
  • Patients that require high acuity care will be sent immediately to an acute bed.

 

Step 2: Vertical Spaces

  • Provide a small area with chairs or recliners;
  • Consider a separate room with television/magazines for those awaiting test results;
  • Use universal treatment carts with supplies that can be moved from patient to patient as opposed to moving patients into a treatment room that contains the appropriate supplies.

 

Step 3: Keeping Patients Vertical

  • Use oral medications, not intravenous, whenever possible;
  • Keep patients in street clothes unless it is necessary to change into a gown;
  • Keep patients off stretchers unless it is necessary; chairs can be equally effective.

Key Takeaways

The concept of the vertical treatment room is designed to mitigate low-acuity patients' use of resources and to improve patient wait times. Vertical treatment rooms require legislative and administrative support in order to be implemented effectively. The payoffs are substantial, with increased provider satisfaction, and patient satisfaction and care. 

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