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MID-TRACK. AHRQ Annual Conference September 27, 2010 Jeffrey Margulies, MD, FACEP. Why: Collateral damage. What: Identifying the Initiative. 2.4% LWBS (left without being seen) Drill Down reveals ESI 3 issue. Who: ESI 3 Conundrum. Patients are too complex for typical fast track visit

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Mid track

MID-TRACK

AHRQ Annual Conference

September 27, 2010

Jeffrey Margulies, MD, FACEP



What identifying the initiative
What: Identifying the Initiative

  • 2.4% LWBS (left without being seen)

  • Drill Down reveals ESI 3 issue


Who esi 3 conundrum
Who: ESI 3 Conundrum

  • Patients are too complex for typical fast track visit

  • Not ill enough to be brought back immediately at times of high census

  • Result: highest LWBS rate for this subgroup of patients

  • Significant potential for morbidity




Where enter the mid track
Where: Enter the Mid-Track

  • Create a solution to address the needs of the ESI 3 patients

  • Insufficient space in current ED

  • ASU located above ED and available after-hours

  • Challenge: find a process that works and uses ASU space


How mid track evolves
How: Mid-Track Evolves

  • Concept: frontload patient visit

  • Nurse categorizes patient as ESI 3

    • Refers to physician sitting in triage

  • Physician in triage, but not triaging

    • Only sees ESI 3 pts with 1 of 6 CC

    • Phlebotomy station set up near triage

    • After initial evaluation pts go up to ASU

    • Care coordinated with NP for entire shift


Lessons learned challenges
Lessons Learned/Challenges

  • Process design quite challenging

  • Start time critical to front loading

    • Bolus of patients when MT starts at 4p

    • Pts ‘triaged’ to MT before 4pm

  • Cost

  • Staffing



Collateral benefits
Collateral benefits

  • Positive response from patients

  • Favored by staff

  • Reduced stress levels in the ED

  • NP role better defined than previously

  • Hospital renewed focus on throughput

  • Mitigated our natural tendency towards procrastination


Future of mid track
Future of Mid-Track

  • Successful initiative to date

  • Expand hours and days of operation

  • Expand ESI 3 patient complaints

  • Included in new ED redesign



Thanks to the team
Thanks to the team!

  • Charles Bové

  • Carol Butler

  • Curt Cicotte

  • Susan Dries

  • Mike Gewirtz

  • Kathleen Lock

  • Tom Nolan

  • Rob Sharma

  • Many others


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