Implementation of Vertical Split Flow Model for Patient Throughput at a Community Hospital Emergency Department
Abstract
Objectives: The objective of this study was to evaluate the impact of vertical split flow (VSF) implementation on emergency department (ED) patient length of stay (LOS) and throughput at a community hospital.
Background: Hospitals have implemented innovative strategies to address overcrowding by optimizing patient flow through the ED. Vertical split flow (VSF) refers to the concept of assigning patients to vertical chairs instead of horizontal beds based on patient acuity.
Methods: This was a retrospective cohort study of all emergency severity index (ESI) level 3 patients presenting to a community hospital ED over a three month period before and after VSF implementation between 2018 and 2019. A vertical area with 10 chairs was separated from the existing ED space and staffed by reassigned advanced practice providers. On arrival, ESI level 3 patients were assigned to the vertical area if they could maintain sitting position during treatment, did not require cardiac monitoring or airborne precautions, and presented no detectable risk of harm to self or others. Unpaired t-tests compared time intervals between cohorts with the primary outcome being ED LOS, as defined by the electronic medical record timestamps for patient arrival to disposition. Secondary outcomes examined throughput using time from patient arrival to bed placement and provider assignment.
Results: In total, 5,262 patient visits in the pre-intervention and 5,376 in the post-intervention group were included in the analysis. There were no significant demographic differences between the two groups. There was a significant reduction in mean overall LOS in minutes between the pre-intervention group (M=283, SD=1.9) and post-intervention group (M=251, SD=1.8), t(10545)=12, p<0.001. There was also a significant reduction in arrival-to-bed (M=9.2, 95%CI 7-11, t(9268)=9.8, p<0.001)) and provider assignment to disposition time (M=31.9, 95%CI 26-36, t(10355)=12, p<0.001)) in minutes with VSF implementation. There was no significant difference in time from arrival to provider assignment (M=0.64, 95%CI -1.2 to 2.4, t(10237)=-0.64, p=0.525), despite a small increase in bed to provider time.
Conclusion: Community hospital ED implementation of VSF for ESI level 3 patients was associated with significant reduction in overall length of stay and improved throughput. This model provides a solution to increase the number of beds in the ED and improve throughput for urgent acuity patients.