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Despite the fact that year-after-year there has been an increasing volume and complexity of emergency department (ED) patients, the number of EDs in the US is actually decreasing.1-3 This increased demand in the face of a decreasing supply of emergency beds has resulted in ED crowding as documented in the 2006 Institute of Medicine (IOM) report Hospital-Based Emergency Care: At the Breaking Point. The consequences of ED crowding are not trivial and include decreased patient safety, worse quality of care, ambulance diversion, lack of timely care, increased patient suffering, and lack of privacy.1-4

As noted in the IOM report, the root problem of ED crowding is ED “boarders,” in-patients utilizing ED beds, resulting in fewer available ED patient access points to evaluate and treat the patients presenting to the ED. Thus, the primary reasons for ED crowding are actually outside of ED operations:

  • Access to inpatient beds for admitted patients
  • Access to operating rooms
  • Increasing complexity of emergency patients
  • Increasing demand for emergency services

Still, the ED leader's goal must be optimize the operational efficiency of the ED to ensure that the best possible care is provided to the greatest number of patients. This chapter will discuss a key methodology of optimizing ED efficiency.

Putting a provider at triage, who can evaluate and treat patients prior to those patients needing an ED bed.3,5-23

Placing a provider at triage enables the ED evaluation to begin regardless of bed availability.12-21 When a provider evaluates a patient, that provider can initiate the ED workup without the delay of waiting for the patient to be placed in a bed—even when that patient returns to the waiting area. For the many ED patients who do not require a bed for diagnostic testing or emergent therapeutic intervention, the provider at triage can evaluate, treat, and discharge the patients immediately with minimal ancillary staffing requirements and minimal use of ED resources and space. Evaluating, treating, and discharging patients without utilizing an ED bed results in bed savings up to 35% to 40% essentially increasing bed capacity by 60%.24 In turn, patients requiring an ED bed for evaluation and treatment can more frequently achieve immediate bedding, resulting in substantial decreases in time to provider for the more seriously ill and injured.

Many hospitals are now utilizing and have documented this provider-at-triage approach. This chapter will detail a proven, reproducible methodology of successfully implementing provider-at-triage and immediate bedding. Both are designed to expedite ED flow and provide data detailing the impact of this program:

  • Decreasing ED waiting times for evaluation and discharge
  • Increasing use of available beds
  • Improving ED patient satisfaction

Relatively few patients require emergent therapeutic procedures prior to diagnostic evaluation. For the remaining majority of patients, the diagnostic evaluation does not require a single evaluation space (location/bed) throughout the ED stay. Rather, the ...

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