White Paper: Improving ED workflow and performance at St. Mary Medical Center

When an emergency department’s workflow is inefficient, wait times can increase, care is not always provided in a timely manner, and patient and staff satisfaction may suffer. This was the situation at St. Mary Medical Center (SMMC) in Apple Valley, California. 

SMMC was struggling with a constrained physical plant space, recurring gaps in ED nursing leadership, prolonged ED lengths of stay, high left without being seen rates, and other performance issues. SMMC executive leadership reached out to Philips Blue Jay Consulting to provide interim ED leadership and help address the issues of efficiency, timely care, and patient/staff satisfaction.

Philips consultants joined SMMC as Interim ED Manager and Interim ED Director, and led an intensive multidisciplinary performance improvement assessment that included a thorough analysis of data collected for volume, arrival patterns, staffing patterns, ESI level distribution, ED billing visit level distribution, disposition breakdown, and length of stay. The assessment identified several areas that were in need of improvement, and resulted in the following actions: 

• Revise front-end processes to include the intake and triage processes
• Re-educate staff on the ESI 5-level triage system
• Restructure leadership and clarify roles of each member of the ED team, increasing accountability for standards of practice and quality of patient care
• Examine use of existing space to optimize workflow
• Implement standard work processes to address the frequent capacity issues in the ED
• Create a shared vision and mission for leadership team

A key component of the PI recommendations was the development of a new process solution termed ‘Middle-Trac’. A derivative of a split-flow process where patients are triaged quickly into parallel care streams, Middle-Trac focuses on patients in the middle (ESI level 3) who do not require immediate treatment. It keeps these patients vertical and moving through the department, not occupying valuable treatment spaces until a disposition decision is made.

Similar to an assembly-line, elements of the Middle-Trac process work cohesively. A triage nurse classifies arriving patients into one of three categories: immediate bed needed, fast track appropriate, and remaining Middle-Trac patient population. A detailed process flow maximizes continuity of care, manages essential resources, and minimizes provider hand-offs