Super TrackThe Evolution of the Split Flow Emergency Department

John D’Angelo, MD, FACEPNorthwell Health

Robert Masters, AIA, NCARB, LEED APCannonDesign

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Agenda

1. Emergency Department Flow

2. Evolution of the Super Track Model at Northwell Health

3. Case Studies: Flow Meets Design

a. Southside Hospital

b. Huntington Hospital

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Learning Objectives

1. The value of the Super Track split-flow organizational approach in emergency departments as an effective lean process re-design strategy.

2. The implications of the Super Track approach on the planning and design of emergency departments, both for renovations and new construction.

3. Examples of how design can impact throughput and average length-of-stay in the emergency department.

4. Strategies that enhance design team and medical team collaboration for better operational and clinical outcomes.

Northwell Health Emergency Medicine Service Line

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Emergency Medicine Service Line

• 5 Tertiary Emergency Departments

• 11 Community Emergency Departments

• 2 Affiliate Tertiary Emergency Departments

• 1 Free-Standing Emergency Departments

• 33 Northwell Health-Go Health Urgent Care Centers

• CVS Minute Clinic Partnership

Clinical Operations

• ~ 900,000 Annual Emergency Department Visits

• >70% of all system inpatient admissions via Emergency Departments

Volume

• Over 340 Full Time/Part Time Physicians (plus another 215 Per-Diem)

• Non Physician Staff ~1,600 FTEs

Workforce

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Emergency Department Flow

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Emergency Service Work Flow

“And this is where our ED workflow redesign team went insane.”

“Every System is Perfectly Designed to Achieve the

Results it Achieves”

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What’s new since most of todays ED’s were built?

Lean Process Re-design:

• Split flow, super tracks, team triage

• Vertical patients, “not every patient needs a room”

• Greater scrutiny on clinical coverage (cost and availability)

Regulatory:

• CMS reporting requirements (LOS, door to X measures)

• P4P

IT:

• EMR, Tracking boards, WOWs, CPOE, biometrics, RTLS, telemedicine

• Consumer focus - At home check in apps, no wait EDs, entertainment options

• Registration Kiosk, tablets, Prescription Kiosk – delivery services

• Real time dashboards

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Population Health / Payer Influence

• Management of frequent utilizers

• Shift of lower acuity patients out to alternative providers (PCPs, UCCs, Retail)

Consumerism:

• Wait time apps and billboards

• Alternative choices: FSEDs, UCCs, Retail

• Patients Satisfaction P4P

Medical Advances and Trends

• Radiology – CT, MRI, Bedside US

• Telemedicine, E-ICU

• Observation Medicine

• Specialty EDs or design components:

Geriatrics, Pediatrics, Cancer, Bariatric

Surge, Infection control (Ebola like processes)

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What’s not new?

Rising Volumes

Hospital Closings

Shrinking inpatient capacity

Rising Acuities

Increase in Behavioral Health issues

Tight staffing

Budgetary constraints

And so on...

The Case for Workflow Redesign

Source: Studer Group and CEP

Improved:

• Patient Satisfaction

• Staff Satisfaction

• Quality of Care

• Reduce Risk

• Department Capacity

• Finances

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IMPROVE CAPACITY!!!

Throughput: “Typical” ED Flow

There are essentially three components to a patient’s visit to the ED

INPUTPatient arrives

THROUGHPUTStuff happens

OUTPUTPatient leaves

Complex Processes Plagued By Bottlenecks

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• Parallel rather than sequential processes

• Direct to bed / treatment area

• Triage bypass / Short Triage

• Quick Registration

• Bedside Registration

• Provider in Triage

• Team Triage

• Super Track / Split Flow

Input: Door to Provider (MD or MLP)

Eliminating Bottleneck & Delays

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• Align the rest of the organization with ED success

• Lab and Rad Turn Around Time (TAT)

• Super Track

• Results Waiting Area / Sub-waiting / other servers

• Keep vertical patients vertical

Throughput: Provider to Disposition

• Improve Admission process – Greatest Challenge and Impact on capacity, throughput and patient safety in most EDs

• Set goals and organize people around them

Output: Disposition Decision to Departure

Eliminating Bottleneck & Delays

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Process:

The Split Flow process is an evidenced based principle of bed conservation where resources are matched with patient flow in order to alter the care process.

The Split Flow Process

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• Replace Triage with “Quick Look” Clinical Assessment for Incoming Patients

• Split Patient Flow

• Vertical/low acuity patients don’t own beds – rapid treatment

• Capacity to meet volume using queuing analyses

Banner Health new ED model for patient flow (2006)

• Rapid triage of each patient by clinical team

• Accelerated treatment (lower acuity patient)

• Quicker admission (higher acuity patient)

• Eight EDs adapted to the two-track patient flow model

The Development of the Split Flow Model

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1. Faster time to treatment: reduced by 58%

2. Fewer walk-out patients: reduced from 7.1% to 1.7%

3. Reduced ED length of stay: reduced by 14%

4. Enhanced capacity to serve patients: increased by 1%

Triage (verb)

Brief RN Assessment ESI Level / Acuity

Low AcuityPathway

ESI Levels 4, 5, some 3’s

Moderate AcuityPathway

Most ESILevel 3’s

High AcuityPathway

ESI Levels1 and 2

~ 30-40% ~ 50-60% ~ 10%

Matching Our Service Delivery to our Incoming Patient Stream

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Does every patient require a bed?

Increase Capacity: Add Space

Vertical Patients

• Ambulatory

• Well / Low Acuity

• Younger

• Perceived Urgency or Convenience Driven

• Value (Starbucks)

• Speed

• Convenience

• Other non-medical factors

Horizontal Patients

• Arrive by Ambulance

• Sick / High Acuity

• Older

• Serious or Life Threatening Condition (real or perceived)

• Value (Traditional Healthcare)

• Safety

• Preserve Life or Limb

What about a chair?

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Parallel vs. Sequential Front End Process

Pt. Arrives

“Quick Look”Triage

Quick Reg

RN / Provider / Tech Team

Main ED

DischargeArea

Testing Station

Results Waiting

Area

Rx / Minor

Procedures

Super Track

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Summary: Potential Super Track Advantages

1. Reduce square footage requirements from traditional ED concept

2. More efficient throughput and reduced ALOS

3. Keep vertical patients vertical

4. Separate lower acuity patients from higher acuity level patients

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Evolution of the Super Track Model at Northwell Health

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Long Island Jewish Medical Center

ED Modernization – 2006

• 21,000 sq. ft. clinical addition

• Comprehensive, multi-phased renovation

• Critical Care, private treatment rooms, Imaging, Behavioral Health, Pediatrics

LSGS Architects/Perkins Eastman LSGS Architects/Perkins Eastman

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Long Island Jewish Medical Center: Adult ED Volume

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20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

110,000

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016Projected

2017Projected

Adult ED Volume Trends

Adult ED Volume Split Flow Capacity Current Capacity

Long Island Jewish Medical Center: Door to Provider Time

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20

40

60

80

100

120

140

Door to Provider Time

Change Implemented

Door to Doc

Mean

UCL

LCL

Long Island Jewish Medical Center: Treat & Release LOS

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240

260

280

300

320

340

360

380

400

Treat and Release LOS

Change Implemented

T&R LOS

Mean

UCL

LCL

Long Island Jewish Medical Center: LWOBEs

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0

0.01

0.02

0.03

0.04

0.05

0.06

LWOBE Percentage

Change Implemented

LWOBE

Mean

UCL

LCL

Long Island Jewish Medical Center: Likelihood to Recommend

26

30

35

40

45

50

55

60

65

70

75

Likelihood to Recommend (Top-Box)

Change Implemented

LTR

Mean

UCL

LCL

Long Island Jewish Medical Center

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Adult ED Split Flow Floor Layout

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Pre Improvement Statistical Analysis of

Door to Doctor LOS –March 2016

Sigma Score 1.2, mean time 94 mins.

Post Improvement Quid 16 hours/7 days

Door to Doctor LOS –September 2016

Sigma Score 1.8, mean time 68.5 mins.

Long Island Jewish Medical Center

102

68

Jan. Sept.

Door to Provider

33% Decrease

3.9

2.1

Jan. Sept.

LWOBE

93,964

98,820

2015 2016

Volume

358

302

Jan. Sept.

T&R LOS

16% Decrease

5% Increase 47% Decrease

Lenox Hill Emergency Department:

• Sees nearly 56,000 patients.

• The new space (south side) had a larger footprint, added privacy, multipurpose rooms, and replaced most stretcher spaces with recliner chairs.

Lenox Hill Hospital

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NORTH SIDE

SOUTH SIDE

Lenox Hill Hospital

Design

FT

Lenox Hill Hospital

New South Side design

• Chairs replace most stretchers

• New Omnicell

• New curtains

• Procedure room

• Adjacent to X-ray

Lenox Hill Hospital: Door to Provider Time

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0

5

10

15

20

25

30

35

40

45

50

Door to Provider Time

Change Implemented

Door to Doc

Mean

UCL

LCL

Lenox Hill Hospital: Treat & Release LOS

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150

170

190

210

230

250

270

Treat and Release LOS

Change Implemented

T&R LOS

Mean

UCL

LCL

Lenox Hill Hospital: LWOBEs

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-0.005

0

0.005

0.01

0.015

0.02

0.025

LWOBE Percentage

Change Implemented

LWOBE

Mean

UCL

LCL

Long Island Jewish Medical Center: Likelihood to Recommend

35

30

40

50

60

70

80

90

Likelihood to Recommend (Top-Box)

Change Implemented

LTR

Mean

UCL

LCL

Flow meets Design!

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Boston

NYC

DC

Phoenix

Los Angeles

Chicago

Buffalo

Baltimore

St. Louis

Vancouver

Toronto

San Francisco

Shanghai

Mumbai

Montreal

Pittsburgh

Our single-firm, multi-office approach offers our clients access to full resources from offices worldwide

• 100 years of legacy

• 16 offices with over 900 personnel

• 550 health care staff

• Single firm, multi-office (SFMO) approach

• 3rd largest practice in the world in volume

• Top 5 ranked healthcare practice for past 20 years

• Fully-integrated Architecture / Engineering / Planning / Interiors / Cost Estimating / Facility Optimization

• In-house Operations, Clinical, and Research capabilities

Who is CannonDesign?

Fixed x-ray unit located adjacent to triage accelerates plain film imaging for walk-in patients

Super Track Model Differentiator

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Placing a physician at triage substantially expedites Arrival-to-Physician evaluation times

Super Track Model Differentiator

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Southside HospitalExisting Emergency Department:

• Area: 11,000 square feet

• Construction: mid-1970s• 22 Treatment Bays• Original volume: 30,000 visits

• Modular addition: 2007• (9 Fast Track Bays)• 56,000 visits• 1 bed : 1,800 visits

• Project Kick Off 2013 • 71,000 visits• 1 bed: 2300 visits

• 2021 projections• 90,000 visits

Existing Emergency Department

Walk-In EntranceAmbulance Entrance

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Current State:

•2013 Volume = 70,634 visits

• Admission rate – 16%

•Current department has 33 beds

•Traditional ED capacity model 1 bed for every 1300 patients / yr

• Current volume 70,634 visits / 1300* = ~ 54 beds

• Projected 2021 volume 87,769 visits / 1300* = ~ 68 beds (~55,000+ sq ft)

Southside Hospital

Problem: Volume exceeds capacity!

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Problem: Volume exceeds capacity

How do you increase capacity?

- Add space, i.e. treatment units (ex. beds)

- Improve throughput / decrease LOS

Recommendation: Do both!

Southside Hospital

Solution: Increase Capacity!

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ED Expansion Design:

• Infill addition

• Expansion into Brackett Pavilion to the west

• New walk-in entrance on the south of the ED

• Dedicated Super Track

• Results Waiting

• Dedicated Behavioral Health Evaluation Area

• Targeted renovations in the existing ED:

• Expanded Trauma & Critical Care

• Expanded Imaging

• Expanded IsolationWalk-In Entrance

Ambulance Entrance

Behavioral Health

Entrance

Southside Hospital

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Southside Hospital

Gradient of Care:

• Concentrating low acuity care at the walk-in entry

• Higher acuity & specialty care radiates from the Super Track hub

• Critical Care Corridor and Isolation Suite developed off of Ambulance entry

1

2

3

4

5

ESI LEVEL

Walk-In Entrance

Ambulance Entrance

BehavioralHealthEntrance

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Super Track ED:

• Clinical greeter

• Intake Rooms

• Super Track bays

• Super Track rooms

• Flexible to Urgent

• Results Waiting

• Low acuity X-Ray Room

• Sub-wait

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1

1

2

2

3

4

3

4

5

5

66

7

7

Southside Hospital

Super Track ED: Clinical GreeterSuper Track ED: Low-Acuity Treatment BaysSuper Track ED: Results Waiting for the Vertical PatientSuper Track ED: Low-Acuity Sub-Waiting

Southside Hospital

Phase 2 ED Expansion:

• Renovating the balance of the existing ED

• Rightsizing support space for Critical Care

• Expanding Emergent Pod to the south

• Flexible Pediatrics area

• 16-bed Observation Unit

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Phase 1B ED Expansion:

• Isolation Suite

• Resuscitation Rooms

• Trauma Room

• Critical Care Imaging

• 16-bed Observation Unit

• Town Hall Meetings

• Share designs and plans with frontline staff; discuss new split flow model

• Respond to staff questions

• Staffing adjustment

• New workflows require changes to the staffing ratios

• Staff Simulation / Training

• Space and workflow walkthrough for staff followed by simulating their new workflows with volunteers as patients

Go Live Preparation

Southside Hospital: Door to Provider Time

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0

20

40

60

80

100

120

Door to Provider Time

Change implemented

Door to Doc

Mean

UCL

LCL

Southside Hospital: Treat & Release LOS

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150

200

250

300

350

400

Treat and Release LOS

Change implemented

T&R LOS

Mean

UCL

LCL

Southside Hospital: LWOBEs

50

-0.01

2E-17

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

LWOBE Percentage

Change implemented

LWOBE

Mean

UCL

LCL

Southside Hospital: Likelihood to Recommend

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0

10

20

30

40

50

60

70

80

90

Likelihood to Recommend (Top-Box)

Change implemented

LTR

Mean

LCL

LCL

Huntington Hospital

Existing Emergency Department:

• Construction: 1983

• Area: 14,400 DGSF

• Current treatment beds: 36 Existing Treatment Positions

• Existing volume: 52,000 visits

• 1 Bed for every 1450 visits

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Current State

Huntington Hospital

How many Main ED Beds are needed for Moderate to High Acuity?ESI

AcuityTotal Percent total

1 62 0.4%

2 993 6.2%

3 8464 52.6%

4 6200 38.5%

5 367 2.3%

50 % of all Patients????

= ESI 1’s, 2’s, 80 % of 3’s

= ~ 32,500 visits

= ~ 27 beds based on 1:1200 ratio

= ~ 32 beds based on 1:1000 ratio

33 % of all Patients????

= ESI 1’s, 2’s, 50 % of 3’s

= ~ 21,500 visits

= ~ 18 beds based on 1:1200 ratio

= ~ 21 beds based on 1:1000 ratio

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Huntington Hospital

ED Renovation Design:

• Addition and partial renovation of existing administrative space

• Dedicated Super Track

• Results Waiting

• New Imaging area

Ambulance Entrance

Walk-In Entrance

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Huntington Hospital

Gradient of Care:

• Concentrating low acuity care at the walk-in entry

• Higher acuity & specialty care radiates from the Super Track hub

• Public corridor separates lower and higher acuity patients

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Super Track ED:

Clinical Greeter

Intake Rooms

Super Track bays

Super Track rooms

Results Waiting

2 X-Ray Rooms and 1 CT Scan Room

Huntington Hospital

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1

2

3

4

5

6

1

2

3

4

5

6

Construction Progress: Clinical GreeterConstruction Progress: Intake RoomsConstruction Progress: Results WaitingConstruction Progress: Super Track Bays

Huntington Hospital

Results Waiting

Results Waiting in Super Track:

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• The solution to your efficiency needs is not always a bricks & mortar solution

• Don’t be afraid to be innovative with your design concepts

• When you are considering a design or re-design:

• Optimize flow• Focus on process engineering• Use improvement science-driven

implementation and iteration• Leverage technology to meet your needs

• Interdisciplinary collaboration will lead to a stronger solution

Key Takeaways

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Super TrackThe Evolution of the Split Flow Emergency Department

Presented by:

John D’Angelo, MD, FACEP, Northwell Health

Robert Masters, AIA, NCARB, LEED AP, CannonDesign

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