Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Emergency department (ED) vertical patient pathways (VPP) assign patients to a dedicated care area with chairs, avoiding the use of traditional ED beds. The effect of reassigning a dedicated vertical emergency physician (EP) onto an established rotational patient assignment (RPA) system, which prospectively assigns arriving patients to EP queues, is unknown. We sought to describe operational outcomes and staff satisfaction with trialing this role.

Methods: We conducted a single-center, hypothesis-generating exploratory pilot at a 56-bed tertiary-care ED in which one 8.75-hour EP shift on five Mondays was repurposed into an 8.75-hour dedicated VPP role within a chair-based vertical patient care area while the rotational patient assignment system remained in place; three prior comparable Mondays served as comparison. Primary outcome was discharged-patient ED length of stay (LOS); secondary outcomes included VPP upgrades to a bed, patient numbers seen by the dedicated shift, and staff satisfaction. We report descriptive analyses.

Results: We analyzed 529 discharged-patient encounters: 199 (37.6%) during the preintervention period and 330 (62.4%) during the postintervention period. Median ED LOS for discharged patients did not demonstrate a consistent directional change, decreasing by seven minutes (3.1%) in the overall ED (226 vs 219 minutes) and increasing by 18.5 minutes (13.0%) among patients initially evaluated via the VPP (142.5 vs 161 minutes). The dedicated VPP EP saw three more patients per shift (21.4%; median 17 vs 14), and VPP upgrades fell from 15/68 (22.1%) to 5/130 (3.8%). Timeliness and communication were rated favorably by 4/4 VPP physician respondents and 10/12 and 16/17 registered nurse/allied health respondents, respectively; 3/4 VPP physician respondents vs 1/29 non-VPP physician respondents supported continuing the model.

Conclusion: Reassigning an existing EP to a dedicated vertical EP role within an ongoing rotational patient assignment system was not accompanied by shortened discharged-patient length of stay. Fewer VPP upgrades and a modest increase in patients seen by the dedicated shift were observed, but patient selection and acuity limit interpretation. Staff reported favorable teamwork within the vertical space, whereas non-VPP physicians reported less manageable workloads and little support for continuing the model.