The Flex Track: Flexible Partitioning Between Low- and High-Acuity Areas of an Emergency Department

Abstract

Study Objective EDs with both low- and high-acuity treatment areas often have fixed allocation of resources, regardless of demand. We demonstrate the utility of discrete-event simulation to evaluate flexible partitioning between low- and high-acuity ED areas to identify the best operational strategy for subsequent implementation. Methods A discrete-event simulation was used to model patient flow through a 50-bed, urban, teaching ED that handles 85,000 patient visits annually. The ED has historically allocated ten beds to a Fast Track for low-acuity patients. We estimated the effect of a Flex Track policy, which involved switching up to five of these Fast Track beds to serving both low- and high-acuity patients, on patient waiting times. When the high-acuity beds were not at capacity, low-acuity patients were given priority access to flexible beds. Otherwise, high-acuity patients were given priority access to flexible beds. Wait times were estimated for patients by disposition and emergency severity index (ESI) score. Results A Flex Track policy using three flexible beds produced the lowest mean patient waiting of 30.9 (95% CI 30.6–31.2) minutes. The typical Fast Track approach of rigidly separating high- and low–acuity beds produced a mean patient wait time of 40.6 (95% CI 40.2–50.0) minutes, 31% higher than the three-bed Flex Track. A completely flexible ED, where all beds can accommodate any patient, produced mean wait times of 35.1 (95% CI 34.8–35.4) minutes. The results from the three-bed Flex Track scenario were robust, performing well across a range of scenarios involving higher and lower patient volumes and care durations. Conclusion Using discrete-event simulation, we have shown that adding some flexibility into bed allocation between low- and high-acuity can provide substantial reductions in overall patient waiting and a more efficient ED.

The Nature and Necessity of Operational Flexibility in the Emergency Department

“…Thus, in some cases, too much flexibility can be just as problematic as too little flexibility and can negatively affect cost and other indicators of performance.This tension between cost and benefits (e.g., quality and timeliness) of flexibility is highlighted in recent work on “partial flexibility” which provides important insights into this relationship. 12,26 …”

“…Introduction of a so-called “Flex Track” area was found to reduce overall patient waiting more than in either a fully flexible ED (i.e., any bed could accommodate any patient) or a rigidly separated fast track area (i.e., beds could only accommodate specific patient types). 12 Additionally, research on operating-room policies for emergent patients found significantly shorter overall wait times when a partially flexible policy was used. 26 While these examples demonstrate the potential benefit of an intermediate level of physical resource flexibility, the optimal amount of flexibility will depend upon the particular ED (resources, patient mix, etc.…”

“…11 Further,flexible schedules and physical resources may enhance responsiveness of EDs for their patients by better matching the variable demand for care with required supplies of physical resources (e.g., beds), people, and space. 7,12,13 Flexibility addresses both the numerator (patient outcomes) and denominator (costs) of value delivered by EDs. Incorporating flexibility into the ED may help maintain or even improve timeliness of care, and potentially patient outcomes, during periods of high demand and uncertainty.…”

Two Hour Evaluation and Referral Model for Shorter Turnaround Times in the emergency department

“…While strategies such as clinical streaming, team‐based assessment and early senior consultation have been employed elsewhere, we believe that THERMoSTAT is the first system to refine these elements and combine them with the forcing function of periodic turnover. Cubicles are recycled in a more proactive manner in order to preserve capacity and suppress the development of queues.…”

Timeliness of interfacility transfer for ED patients with ST-elevation myocardial infarction

“…Multiple strategies hold promise. For example, activating EMS transportation prior to PCI center activation, 24 using the 911 system to transfer patients, 25 using operations research tools to enhance the operational flexibility of the ED, 26,27 enhancing regionalization efforts to reduce EMS response times, 28,29 standardizing the initial interaction with EMS (eg, patient staying on the stretcher), 24 enhancing hospital-EMS relationships, 22 and appropriate use of ground-based (rather than helicopter) EMS. 19,20 …”