Care models for the front door and the streams

Some care models change who starts a patient’s tests, and some move patients out of the main beds. This article covers both: Nurse Standing Orders and Provider in Triage at the front door, and the four care models in the STREAMS group, Results Waiting Area, Vertical Flow, Fast Track and Super Track. Each is placed from the palette or switched on in a scenario. See Care models for the marks, the boxes of each and how a scenario uses them. The card of each care model shows its cost to run a day, a year, a visit and a patient.

Rest the pointer on its name and its sentence appears: “The triage nurse starts tests from an approved order set; the provider adds what the set missed.” It is marked from any size and needs no other care model.

After triage, a patient at ESI 1 to 3 with chest pain, shortness of breath, abdominal pain or a urinary complaint is given an order set, 80 percent of them to start with. Those complaints are 11.3 percent of visits. The lab and imaging orders of the set start at once, not after the exam. At the exam the provider orders more of the same kind for 69 percent of them. The patient waits in Waiting for Results for every result, early and late.

A patient who comes by ambulance, or who is roomed at once and triaged in the room, as Direct Bedding does, does not pass triage and gets no set. The triage nurse spends 3 more minutes on each patient given a set, so the triage queue can lengthen in a busy hour. The care model adds no staff, spaces or resources: the same tests run, started earlier.

A scenario shows the boxes Chest pain, percent, Shortness of breath, percent, Abdominal pain, percent, Urinary complaints, percent, Highest ESI given a set, Set given, percent, Extra triage minutes and More ordered at exam, percent.

Order to result counts from the order, so for an early order the time includes the patient’s wait. The hover of Lab order to result and Imaging order to result on the Flow tab says so. If Lab in Detail or Imaging in Detail was placed after Nurse Standing Orders, it depends on it, and it comes out first: see Add, move and remove a care model.

Provider in Triage now also orders tests at triage for the patients it sends on. Two boxes in a scenario set it: Ordered at triage, percent and More ordered at exam, percent. The main exam orders more of the same kind for 30 percent of them. See Care models for the rest of what it does.

A stream is a lane for one kind of patient. Each of the four adds its own staff and spaces. Vertical Flow and Fast Track add a team of their own, and the main floor’s providers and nurses do not see their patients. Each space a stream adds is cleaned by that area’s own nurse or tech: see Cleaning beds, chairs and rooms.

“Stable patients with tests pending wait in a chair, so the bed goes to the next patient.” After orders are placed, a share of ESI 3, 4 and 5 patients (40, 80 and 90 percent to start with) moves from the bed to a results chair. The bed goes to the next patient. The patient keeps the provider and the nurse. When the lab and imaging results are back, the patient has a short review in the chair and goes on to Disposition. ESI 1 and 2, and patients with no tests, are not changed.

The move takes about 2 minutes and the review about 7. The wait for results is the same as before, spent in a chair. It adds 20 chairs and one monitoring RN. The patient’s bed is cleaned by the EVS crew, and each chair by the monitoring RN before its next patient.

It is marked Possible from 1,000 visits a space and Suited from 1,250. Its boxes are the three shares, Results chairs, Move to the chair time, Results review time and Clean time, results chair.

“In the day hours, ESI 4, ESI 5 and some ESI 3 patients sit in recliners, never in a bed.” After triage, ESI 3 to 5 patients are sorted at the door during the hours. ESI 4 and 5, and a share of ESI 3, go to a recliner and the vertical provider, and never take a bed. They then go on to Orders or Disposition as before, and Results Waiting Area moves those with tests pending to chairs. The rest go to the Waiting Room. A patient sent to a recliner does not pass Provider in Triage, Team Triage or Tele-Triage.

Vertical Flow needs Results Waiting Area. The door sort takes under a minute and seating about 2. The vertical exam takes as long as the main exam does for the same acuity. It adds 10 recliners, and one APP, one RN and one technician. Each recliner is cleaned by the Vertical RN before its next patient. The share of ESI 3 patients who can sit does not yet rise with how full the department is.

It is marked Possible from 18,000 visits and Suited from 37,000. Its boxes are Vertical opens, Vertical closes, ESI 3 who can sit, percent, Recliners, Vertical providers, Seat in recliner time and Clean time, recliner.

“In the day hours, ESI 4 and 5 patients leave the waiting room for a minor care lane.” During the hours, ESI 4 and 5 patients leave the Waiting Room for Fast Track. They wait in its own queue for a room and a share of the team’s load, and they can walk out of it. An APP and an RN see them, treat them and send them home. A few percent are sent on to the main ED, and give up their share. Outside the hours, ESI 4 and 5 use the main beds as before.

The exam takes about 20 minutes whatever the acuity. It adds 8 rooms, two APPs, two RNs and one technician. The team holds up to 6 units of load: an ESI 5 patient counts 1 and an ESI 4 patient counts 1.5. Each room is cleaned by the Fast Track tech before its next patient. A Fast Track that is understaffed can make its own patients wait longer than the main ED does. It uses a step of the kind Fast Track screen.

It is marked Possible from 15,000 visits and Suited from 40,000. Its boxes are Fast Track opens, Fast Track closes, Share sent to main ED, percent, Fast Track rooms, Fast Track APPs, Fast Track exam time and Clean time, Fast Track room.

“The simplest ESI 4 and 5 patients go to chairs and are seen, treated and sent home in one step.” Before Fast Track takes a patient, a share of ESI 5 (95 percent to start with) and ESI 4 (50 percent) go to a chair and are seen, treated and sent home in one step, with no orders. The rest go on to a Fast Track room as before. Super Track works only during Fast Track’s hours.

Super Track needs Fast Track. The one step takes about 18 minutes, from 10 to 30. It adds 6 chairs, one APP and one RN, apart from the Fast Track team. Each chair is cleaned by the Super Track RN before its next patient. A shorter length of stay is not promised.

It is marked Possible from 35,000 visits and Suited from 70,000. Its boxes are ESI 5 sent to chairs, percent, ESI 4 sent to chairs, percent, Super Track chairs, Super Track visit time and Clean time, Super Track chair.

• Care models: the nineteen care models, their marks and their boxes.
• Add, move and remove a care model: the card, Add and Remove Care Model.
• Cleaning beds, chairs and rooms: who cleans each space.
• The emergency department report tabs: the Front Door tab and the time tables the streams change.