ORIGINAL RESEARCH CONTRIBUTION

Decreasing Length of Stay in the Emergency

Department With a Split Emergency Severity
Index 3 Patient Flow Model
Rajiv Arya, MD, Grant Wei, MD, Jonathan V. McCoy, MD, Jody Crane, MD, MBA, Pamela Ohman-
Strickland, PhD, and Robert M. Eisenstein, MD

Abstract
Objectives: There has been a steady increase in emergency department (ED) patient volume and wait
times. The desire to maintain or decrease costs while improving throughput requires novel approaches
to patient flow. The break-out session “Interventions to Improve the Timeliness of Emergency Care” at
the June 2011 Academic Emergency Medicine consensus conference “Interventions to Assure Quality in
the Crowded Emergency Department” posed the challenge for more research of the split Emergency
Severity Index (ESI) 3 patient flow model. A split ESI 3 patient flow model divides high-variability ESI 3
patients from low-variability ESI 3 patients. The study objective was to determine the effect of
implementing a split ESI 3 flow model has on patient length of stay (LOS) for discharged patients.
Methods: This was a retrospective chart review at an urban academic ED seeing over 70,000 adult
patients a year. Cases consisted of adults who presented from 9 a.m. to 11 p.m. from June 1, 2011, to
December 31, 2011, and were discharged. Controls were patients who presented on the same times
and days, but in 2010. Visit descriptors included age, race, sex, ESI score, and first diagnosis. The first
diagnosis was coded based on methods used by the Agency for Healthcare Research and Quality to
codify International Classification of Diseases, ninth version, into disease groups. Linear models
compared log-transformed LOS for cases and controls. A front-end ED redesign involved creating
guidelines to split ESI 3 patients into low and high variability, a hybrid sort/triage registered nurse, an
intake area consisting of an internal results waiting room, and a treatment area for patients after initial
assessment. The previous low-acuity area (ESI 4s and 5s) began to see low-variability ESI 3 patients as
well. This was done without additional beds. The intake area was staffed with an attending emergency
physician (EP), a physician assistant (PA), three nurses, two medical technicians, and a scribe.
Results: There was a 5.9% decrease, from 2.58 to 2.43 hours, in the geometric mean of LOS for
discharged patients from 2010 to 2011 (95% confidence interval CI = 4.5% to 7.2%; 2010, n = 20,215;
2011, n = 20,653). Abdominal pain was the most common diagnostic grouping (2010, n = 2,484; 2011,
n = 2,464) with a reduction in LOS of 12.9%, from 4.37 to 3.8 hours (95% CI = 10.3% to 15.3%).
Conclusions: A split ESI 3 patient flow model improves door-to-discharge LOS in the ED.
ACADEMIC EMERGENCY MEDICINE 2013; 20:1171–1179 © 2013 by the Society for Academic
Emergency Medicine

From the Department of Emergency Medicine (RA, GW, JVM, RME) and the Department of Biostatistics (PO), UMDNJ/ Robert
Wood Johnson Medical School, New Brunswick, NJ; and the Mid-Atlantic Permanente Medical Group (JC), Rockville, MD.
Received April 19, 2013; revision received June 12 and June 18, 2013; accepted June 20, 2013.
Presented at the Society for Academic Emergency Medicine Annual Meeting, Atlanta, GA, September 2013.
The authors have no relevant financial information or potential conflicts of interest to disclose.
Supervising Editor: Lowell Gerson, PhD.
Address for correspondence and reprints: Rajiv Arya, MD; e-mail: aryara@umdnj.edu.
Consensus Conference Follow Up 2011.
Editor’s Note: Academic Emergency Medicine highlights articles that follow up on the research agendas created at the journal’s
annual consensus conferences. This article relates to the 2011 AEM consensus conference, “Interventions to Assure Quality in the
Crowded Emergency Department.” All prior consensus conference proceedings issues are available open-access at www.aemj.
org, and authors interested in submitting consensus conference follow-up papers should consult the author guidelines. http://
onlinelibrary.wiley.com/journal/10.1111/%28ISSN%291553-2712/homepage/ForAuthors.html.

© 2013 by the Society for Academic Emergency Medicine ISSN 1069-6563 1171
doi: 10.1111/acem.12249 PII ISSN 1069-6563583 1171
1172
T
here has been a steady increase in emergency
department (ED) patient visits and a decrease in
the number of EDs over the past 20 years.1
Recently enacted legislation aimed at reducing costs
and increasing access will likely further increase ED
demand while driving the necessity for reducing cost
per patient. This need to decrease cost and improve
throughput requires novel approaches to patient flow.
The breakout session “Interventions to Improve the
Timeliness of Emergency Care” at the June 2011
Academic Emergency Medicine consensus conference
“Interventions to Assure Quality in the Crowded Emer-
gency Department” posed the challenge for more
research on the split Emergency Severity Index (ESI) 3
patient flow model and greater efficiency.2,3
The ESI is reported to be the most commonly adopted
triage acuity system in the United States.4,5 Similar
scales are in use in Canada, the United Kingdom, Aus-
tralia, and other countries. The boards of the American
College of Emergency Physicians and the Emergency
Nurses Association support the adoption of five-level
triage scales. ESI’s five-level system is driven by patient
acuity and resource utilization.6 Levels 1 and 2 are
distinguished by instability of vital signs or severity of
presenting complaint, while levels 3, 4, and 5 are con-
sidered less acute and thus are differentiated by the
number of resources required. Examples of resources
include diagnostic testing and interventions. Level 4 and
5 patients require one or no resources, respectively, and
are traditionally treated in designated low-acuity areas
of the ED such as “fast tracks.” A split patient flow
model for ESI Level 3 patients segments high-variability
and low-variability ESI 3 patients into separate streams
with the intent of driving them through a more custom-
ized and efficient process. The ultimate goal is to reduce
variability in the care of these patients, realizing
improvements in metrics such as door-to-doctor times,
length of stay (LOS), left without being seen, and patient
satisfaction.7 The benefits of reducing variability have
been described in fast track settings.8–10 The split-flow
model works in a similar manner, reducing variability,
reducing LOS, and enhancing service responsiveness.
An ever-growing body of literature demonstrates the
many negative consequences of the ED overcrowding
and boarding crisis.11,12 Downstream effects include
delays in care, decreased patient and physician satisfac-
tion, and increased patient mortality.13–16 Our objective
was to determine the effect of implementing a split ESI 3
flow model has on patient LOS for all discharged patients.
METHODS
Study Design
We conducted a retrospective chart review to examine
the effect of a split ESI 3 flow model on the LOS for
patients who were discharged from the ED. The process
had a go-live date of May 31, 2011. The study protocol
was approved by the institutional review board of the
medical school.
Study Setting and Population
This study was conducted in an urban, academic ED that
sees over 70,000 adult patients a year. Cases consisted of
Arya et al. • DECREASING LOS WITH SPLIT ESI PATIENT FLOW
adults, age greater than 21 years, who presented from 9
a.m. to 11 p.m. from June 1, 2011, to December 31 2011.
Controls were patients who presented the same time
and the same calendar days in 2010.
Study Protocol
Our site implemented a split ESI 3 flow model to effi-
ciently manage patients presenting during the busi-
est hours of the day, 9 a.m. to 11 p.m. The
implementation of a split ESI 3 flow model required six
major changes: splitting of ESI 3 patients, infrastruc-
ture, staffing, responsibilities, purpose of the area, and
a roll-out plan. Each will be described in detail, and
then a few patient examples will be presented to dem-
onstrate the application.
Splitting ESI 3 Patients. The intake17 area saw all ESI
4 and 5 patients as well as low-variability ESI 3. Low-
variability ESI 3 patients required two or more
resources and typically follow a standardized work flow:
assessment, diagnostics, medications, and one reassess-
ment prior to disposition. They rarely require significant
physician or physician assistant (PA) attention above
and beyond the initial assessment and final disposition
reassessment. The physician and nursing leadership
worked together and created a guide to determine who
was considered a low-variability ESI 3. Some of the rec-
ommendations are institution-specific; e.g., we are
unable to perform a private pelvic examination in the
intake area (Table 1). The team determined that the
intake area would see about six patients per hour,
between a physician and PA, and wanted to limit the
patients to those who required no more than 20 min-
utes of provider time for assessment, orders, and reas-
sessment.
Infrastructure. Intake was divided into four distinct
zones: assessment, treatment area, results waiting room,
and the discharge area. The intake assessment area was
equipped with six reclining chairs where the staff per-
formed assessments and procedures and administered
initial treatments. In addition to the six assessment
chairs, a discharge chair was designated to review
results with patients and perform the discharge encoun-
ters. The assessment area was our prior fast track and
required no construction. The treatment area consisted
of seven curtained treatment bays with stretchers,
which were previously part of the main ED. During the
times intake was open it was used for those patients
and returned to the main ED after intake closed. The
bays were the closest to the intake assessment area and
no construction was required. The results waiting room
was defined as an internal waiting room and contained
five reclining chairs with a TV, a desk, and a computer.
The results waiting room was a conference room that
was repurposed to clinical space and only required
cosmetic changes. The discharge area was a pediatric
triage room near the front entrance of the ED that was
no longer in use and was converted to a registration
work space.
Staffing. The intake assessment area was staffed with
one emergency physician (EP), one PA, one scribe, two
ACADEMIC EMERGENCY MEDICINE • November 2013, Vol. 20, No. 11 • www.aemj.org 1173

Table 1
Guide to Sort for Split of ESI 3

Sort to Intake Do Not Sort to Intake

Head and neck Abdominal complaint (in extremis)
Dental complaint Headache, rule out meningitis
Ear complaint Headache, “worst headache of life”
Eye complaint Chest pain (except as described in intake)
Sore throat Shortness of breath (except as described in intake)
Facial complaint Altered mental status
Head injury, normal MS Weakness, >40 yr
Neck pain Dizziness, >40 yr
Headache—history of migraines not “worst headache of life” Syncope
Nose bleeds Cerebrovascular accident
Chest Hypotension
Cough/congestion age < 60 yr Symptomatic hypertension
Asthma Fall, >60 yr (if not able to ambulate)
Shortness of breat—possible bronchitis, respiratory Vaginal complaint (bleeding, discharge, etc)
Breast complaint Pelvic pain
Genitourinary Oncology patients
Groin complaint Transplant patients
Urinary complaint (level 3) Any condition requiring isolation (i.e., chicken pox, shingles)
Penile discharge/pain/complaint Pregnancy related
Ortho Any patient requiring cardiac monitoring
Extremity pain—stable, no obvious deformity, no open wound.
Back pain, ambulatory, minor accident/injury
Leg swelling possible deep venous thrombosis (level 3)
Skin
Abscess
Laceration
Rash
Cellulitis—exclude extensive cellulitis
Allergic reaction
Wound check
Skin problem
Puncture wound
Foreign body
Insect bite
Animal bite
General
Flu-like symptoms—age < 40 yr
Other
Rabies
Medication refill
Superficial bleeding
Extremity swelling—trauma (level 4)
Motor vehicle crash—only musculoskeletal
Abdomen
Abdominal pain—not in extremis, age < 55 yr
Flank pain—age <40 yr
Nausea or vomiting
Rectal complaint
Minor gastrointestinal bleed

ESI = Emergency Severity Index.

nurses, and one medical technician. The results waiting
room was staffed by one medical technician. The treat-
ment area was staffed by one nurse, and the discharge
kiosk was staffed by a registration clerk who completed
the final registration paperwork. There was no increase
in the physician or PA staffing hours. Sixteen additional
nurse and medical technician hours were added.
Responsibilities and Purpose. Each provider was
accountable to ensure that each patient flowed smoothly
through the process (Table 2). The triage nurse or the
assessment nurses would direct-bed the patient based
on initial presenting complaint, which was compared to
the list created by the team to determine the proper
assessment area for the patient. The physician or PA
would perform the medical evaluation and assessment.
The scribe would prepare the medical record, update
the providers on results, and prepare discharge instruc-
tions and prescriptions. After placing the patient in a
treatment bed, the assessment nurse would place the
initial intravenous (IV) line, draw blood, and medicate
the patient as needed. The assessment medical techni-
cian would transport the patient to radiology and per-
form general medical technician duties. The treatment
nurse would provide ongoing management of the
patient and would update the physician and PAs to the
patient’s progress. The results waiting room medical
technician would transport the patient in and out of the
1174 Arya et al. • DECREASING LOS WITH SPLIT ESI PATIENT FLOW

Table 2
Intake Infrastructure, Staffing, and Purpose

Area Staffing Beds Purpose

Intake assessment One physician Six reclining chairs, Assessment, initial medications, phlebotomy, and procedures.
One PA one discharge chair
Two nurses
One medical
technician
One scribe
Results waiting One medical Five lounge chairs Decompress the clinical assessment area while patients wait
technician for consultants, ancillary services, and results.
Treatment One nurse Seven stretchers Provide medical treatment for patients that are not safe to sit
in a lounge chair.
Discharge kiosk One registration Completion of the registration process that does not occupy
clerk a clinical space.

PA = physician assistant.

room, would observe each patient for change in condi-
tions, and would keep the patient informed as to the
status of his or her test results and treatment progress.
Each area within intake had a unique role relative to
the overall flow. The assessment area is where the phy-
sician and PA would see the patients and the nurses
would perform initial nursing tasks. The treatment area
enabled patients who could not stay vertical during
their entire clinical encounter (i.e., those medicated with
IV opiates) to assume treatment beds while undergoing
evaluation and management. The results waiting room
provided an additional, more efficient location for
patients to await ancillary results, enabling the assess-
ment area to maintain flow and enhancing overall bed
capacity. Finally, the discharge area allowed the collec-
tion of the financial information and the completion of
the registration process to occur in a nonclinical setting,
further improving bed capacity. The main ED had bed-
side registration.
Patient Flow. In this flow model, patients initially pre-
sented to the registration clerk, who performed quick
registration (name, date of birth, chief complaint). Based
on the chief complaints, patients were pulled into the
intake area or waited for a more traditional triage
encounter (Figure 1). Those patients pulled directly to
Quick
Registration
Triage/Sort Intake Area
Results
Waiting Room
Discharge
Kiosk
To the Main
ED
Figure 1. Process for split ESI 3. ESI = Emergency Severity
Index.
the intake area were often seen by the nurse and pro-
vider simultaneously, further streamlining the process.
For example, a suspected renal colic patient, an ideal
example of a low-variability ESI 3 patient, would be
seen by the physician and initial medications and fluids
started in intake. From there the patient would go to
radiology for a computed tomography scan and would
return to either the results waiting room or the treat-
ment area, depending on the type of medication he or
she was given in intake. High-risk medications, such as
IV opiates, required the patient to go to a treatment
bed, while patients receiving oral pain relievers, which
they could otherwise take at home, could be managed
from the results waiting room. For a patient having
continued symptoms, the treatment nurse would contact
the intake physician for additional medication orders.
When all of the diagnostic testing was complete and
resulted and the nurse felt the patient was clinically
ready for discharge, the treatment nurse would contact
the physician to discharge the patient.
Rollout Plan. The ED redesign team was composed of
EP and nursing leadership along with three staff physi-
cians, one staff PA, two staff medical technicians, and
six staff nurses who worked to tailor the split ESI 3 flow
model to our department. A rapid-cycle testing model
for process improvement was employed with 10
pilot days that were performed prior to going live on
May 31, 2011.18 The test pilots solidified the timing,
staffing, responsibilities, patient flow, and education of
the splitting of the ESI 3. To differentiate between low-
and high-variability ESI 3 patients, the nursing staff
composed a list of qualifying chief complaints. Where
there were disagreements, the nursing design team
Treatment
reviewed selected triage encounters in a blinded fash-
Area
ion, each rating the patient encounter as intake or main.
The cases where there was a definite majority opinion
Discharge
were incorporated into the final criteria, and the staff
was subsequently educated on these criteria (Table 1).
Admission
Data Extraction. An electronic medical record (EMR)
was used to extract patient demographics, clinical data,
arrival and discharge times, and the final disposition.
The EMR recorded a time stamp for each significant
ACADEMIC EMERGENCY MEDICINE • November 2013, Vol. 20, No. 11 • www.aemj.org
patient milestone. The main outcome variable, LOS for
discharged patients, was calculated as the difference in
time between when the patient was entered (arrival
time) and removed (discharge time) from the EMR.
Patients were entered into the EMR by the quick regis-
tration clerk. All patients were manually removed from
the EMR by one of the following individuals: nurse,
physician, PA, registration clerk, or scribe. Visit de-
scriptors included age, race, sex, ESI score, and first
diagnosis. The first diagnosis was coded based on
methods used by the Agency for Healthcare Research
and Quality to codify International Classification of Dis-
eases, ninth version, into disease groups.19
Data Analysis
Descriptive statistics summarized the distributions of
both the outcome of interest LOS for each visit and the
visit descriptors. Independent-sample t-tests and
chi-square tests were used, as appropriate, to compare
distributions of the visit descriptors across years.
Since LOS was positively skewed, a log-transforma-
tion was taken to stabilize the variance before more
formal inferential statistics were conducted. Additional
histograms confirmed that this resulted in bell-shaped
distributions for the LOS, with homogeneous variances
between cases and controls. Linear models compared
log-transformed LOS for cases and controls, both
unadjusted as well as adjusted for age, race, and sex.
These analyses included a random effect for patient to
account for correlations between visits by the same
patient.
All analyses were conducted using SAS for Windows,
version 9.3 (SAS Institute Inc., Cary, NC). Results are
expressed as geometric means and percent changes in
these means, calculated as the exponential of the
least-square means of the adjusted means of the log-
transformed values or the regression coefficients sum-
marizing the difference between adjusted means,
respectively. Use of the log-transformed values and geo-
metrics means to summarize results ensures that the
Table 3
Distribution of Visit Characteristics and p-values for Detecting Differences Between Controls and Cases
Characteristic Controls
Age (yr), mean (SD) 43.4 (16.9)
Sex
Male 9,069 (44.9)
Female 9,256 (55.1)
Race
Asian 1,099 (5.4)
Black or African American 4,895 (24.2)
Multiracial 30 (0.2)
White non-Hispanic 8,987 (44.5)
Unknown/unavailable 5,204 (25.7)
ESI score (missing n = 51)
1 8 (0.04)
2 1,912 (9.5)
3 9,373 (46.4)
4 7,544 (37.3)
5 1,364 (6.8)
Data are reported as n (%) unless otherwise noted.
ESI = Emergency Severity Index.
1175
overall results are not strongly influenced by the extreme
values in the tail of the positively skewed distribution.
Additional exploratory analyses evaluated whether
ESI score or diagnosis code (where analyses were
restricted to the 12 most common diagnoses) modified
the difference between cases and controls. In these
analyses, indicator variables were used to represent the
categories of ESI or diagnosis code. Interactions
between case/control status and the modifiers were
used to assess effect modification. With two modifying
variables of interest, it was noted whether they were
significant while maintaining a familywise error rate of
0.05 using the Bonferroni correction.
RESULTS
We analyzed 20,653 cases from 2011 and 20,215 con-
trols from 2010 for the study period. ESI level differed
significantly across years. No other visit descriptors dif-
fered significantly across years (Table 3). Linear models
found significant differences between cases and con-
trols, both unadjusted and adjusted for sex, age, and
race (p < 0.0001). Using the unadjusted regression coef-
ficients, we estimate that there was a 5.9% decrease
(calculated as [exp(beta for year) – 1) 9 100%]) in the
geometric mean of LOS from controls relative to cases
(95% confidence interval [CI] = 4.5% to 7.2%). The
adjusted estimates were similar.
We found that ESI significantly modified the differ-
ence in LOS between cases and controls (p = 0.0086).
That is, the difference varied by levels of ESI. Thus,
these results were further stratified by ESI and first
diagnosis code (12 most frequent; Table 4). For visits
with ESI 1 (most critical), the difference between cases
and controls was not significant (p = 0.40). For ESI 2,
the difference was marginally significant (p = 0.033);
however, the lower endpoint of the 95% CI was very
close to zero. For ESI 3 or 4, LOS for cases were signifi-
cantly lower than those for controls (p = 0.0011 and
0.0060). In particular, the cases had LOS that were
Cases p-value Comparing Controls With Cases
43.1 (16.9) 0.1631
11,146 (49.4) 0.93
11,397 (50.6)
1,130 (5.5) 0.98
4,946 (24.0)
29 (0.14)
9,204 (44.6)
5,344 (25.9)
20 (0.1) <0.0001
1,671 (8.1)
8,978 (43.6)
8,311 (40.3)
1,636 (7.9)
1176 Arya et al. • DECREASING LOS WITH SPLIT ESI PATIENT FLOW

Table 4
Unadjusted Differences in LOS Between Controls and Cases by ESI and First Diagnosis Code

N Geometric Mean (95% CI) Linear Model Results

Diff % 95% CI for%
Variable Controls Cases Controls (Min) Cases (Min) (Min) p-value Difference Difference
Overall 20,215 20,653 155.3 (153.8 to 156.9) 146.2 (144.7 to 147.7) –9.1 <0.0001 –5.9 –7.2 to –4.5
ESI score*
1 8 20 361.7 (241.9 to 540.7) 295.2 (232.7 to 374.7) –66.5 0.40 –18.4 –48.8 to 30.3
2 1,912 1,671 275.7 (268.6 to 282.9) 286.9 (279.4 to 294.5) 11.2 0.033 4.1 0.3 to 8.0
3 9,373 8,978 210.8 (208.1 to 213.4) 204.4 (201.5 to 207.3) –6.4 0.0011 –3.0 –4.8 to –2
4 7,544 8,311 105.1 (103.5 to 106.7) 102.1 (100.6 to 103.6) –3.0 0.0060 –2.9 –4.8 to –0.8
5 1,364 1,636 73.6 (71.2 to 76.1) 70.6 (68.6 to 72.6) –3.0 0.056 –4.2 –8.2 to 0.1
Diagnosis†
Abdominal 2,484 2,464 262.0 (256.8 to 267.2) 228.2 (223.2 to 233.4) –33.8 <0.0001 –12.9 –15.3 to –10.3
pain
Back problem 1,137 1,015 112.6 (107.7 to 117.7) 109.7 (107.7 to 114.9) –2.9 0.42 –2.5 –8.5 to 3.8
Chest pain 959 974 249.8 (240.3 to 259.7) 247.7 (237.4 to 258.6) –2.1 0.77 –0.8 –6.3 to 5.0
Headache/ 741 744 180.1 (171.0 to 189.7) 148.0 (140.8 to 155.5) –32.1 <0.0001 –17.8 –23.3 to –11.9
migraines
Open wound 653 704 106.4 (101.8 to 111.2) 107.8 (103.1 to 112.8) 1.4 0.67 1.4 –4.8 to 7.7
extremities
Other 611 647 143.6 (136.9 to 150.7) 139.1 (132.1 to 146.5) –4.5 0.38 –3.1 –9.8 to 4.0
connective
tissue
Other joint 510 553 110.5 (104.3 to 117.0) 104.1 (98.4 to 110.0) –6.5 0.13 –5.8 –12.9 to 1.8
disease
Other lower 692 755 166.6 (158.7 to 174.8) 160.8 (152.7 to 169.2) –5.7 0.32 –3.5 –9.9 to 3.4
respiratory
Other injury 558 589 137.7 (130.4 to 145.4) 137.4 (130.1 to 145.1) –0.3 0.96 –0.2 –7.6 to –7.8
Skin infection 533 469 101.8 (96.3 to 107.7) 92.7 (87.6 to 98.1) –9.1 0.022 –9.0 –16.0 to –1.4
Sprain 1,372 1,411 115.0 (111.6 to 118.5) 102.5 (99.6 to 105.5) –12.5 <0.0001 –10.8 –14.5 to –7.1
Superficial 1,072 1,161 124.9 (120.4 to 129.5) 113.9 (110.0 to 118.1) –11.0 0.0004 –8.7 –13.2 to –4.0
injury

ESI = Emergency Severity Index; LOS = length of stay.

*The difference between cases and controls differed significantly across ESI (p = 0.0068).
†The difference between cases and controls differed significantly across diagnosis code (p < 0.0001; analyses included data only
with 12 most frequent diagnosis codes).

estimated to be 3.0 and 2.9% smaller than those for con-
trols, respectively. The difference in LOS for patients
with ESI values of 5 was similar to those with values of
3 or 4, but not significantly.
Diagnosis was also found to significantly modify the
difference between cases and controls (p < 0.0001;
Table 4). Among the top 12 most common diagnoses,
the largest effects were seen for the following visits:
headache/migraine (%diff = –17.8%; p < 0.0001),
abdominal pain (%diff = -12.9%, p < 0.0001), skin infec-
tion (%diff = –9.0%, p = 0.022), sprains (%diff = –10.8%;
p < 0.0001), and superficial injury (%diff = -8.7%,
p = 0.0004). In other words, for visits in which the diag-
nosis was headache/migraine, the LOS for cases was
estimated to be 17.8% less than for controls. Differences
between cases and controls were not significant for the
remaining seven of the 12 most common diagnoses
(back problem; chest pain; open wound, extremity;
other, connective tissue; other, joint disease; other,
lower respiratory; and other injury). Figure 2 shows
these estimated differences with their 95% CIs. The
diagnoses for which significant effects were found
accounted for 30.7 and 30.3% of all controls and cases,
respectively, while the diagnoses for which nonsignifi-
cant effects were found accounted for 25.3 and 25.4% of
controls and cases. Note that both interactions were
significant at the 0.025 significance level, the level that
would be required to maintain a familywise error rate
of 0.05 using the Bonferroni correction for the effect
modifications.
DISCUSSION
We found an 9% to 18% (9 to 34 minutes) reduction in
LOS for five of the 12 most common complaints (the five
account for about one-third of all ED visits) and a 5.9%
reduction in LOS for all patients. It is important to note
that this improvement occurred in the setting of a sig-
nificant increase in volume of 3.94% (from 40,564 to
42,162) during the study period. The central premise of
splitting ESI 3 visits into high and low variability is to
take advantage of the segmented flow process of a
traditional fast track area. Segmenting patient flow pro-
cesses is beneficial when there are significant differ-
ences in patient characteristics, number or types of
activities in the process, or provider demands that can
potentially result in enhanced throughput in one or both
of the segmented streams. The low-variability ESI 3
patients all followed a standardized work flow: assess-
ment, diagnostics, medications, and reassessment to
disposition. The higher-variability ESI 3 patients had
more complex initial presentations and required
ACADEMIC EMERGENCY MEDICINE • November 2013, Vol. 20, No. 11 • www.aemj.org
% Difference (with 95% CI) of Cases Relative to Controls
for Top 12 Most Common Diagnoses
Headache/Migraines
Abdominal Pain
Sprain
Skin Infection
Superficial Injury
Other Joint Disease
Other Lower Respiratory
Other Connective Tissue
Back Problem
Chest Pain
Other Injury
Open Wound Extremities
-30 -20
Figure 2. Percent difference (with 95% CI) of cases relative to controls for top 12 most common diagnoses.
multiple reassessments throughout their stays by vari-
ous staff members.
The intake area provided a more efficient, fast track–
like setting for a stream of patients who are not tradi-
tionally considered appropriate for this type of process.
Our results show that there are other presenting patient
streams that can benefit from an enhanced process
design that is similar to a fast track environment. These
patient streams have predictable, low-variation evalua-
tion and treatment pathways with low physician and
nursing demands. These patients are relatively well and
unlikely to require admission. Staff and resources can
be better aligned to the patient arrivals during specific
time periods based on expected service times for the
nurse, physician, and the treatment space (recliner
chair). The results waiting room allowed us to minimize
the occupancy of treatment spaces by patients who are
clinically well and reduced the effect of laboratory and
radiology turnaround times and consultant response
time on the capacity of ED treatment beds. The dis-
charge area permitted the registration to occur in a
nonclinical space, improving bed capacity in a similar
manner. This conservation of bed capacity likely
explains the improved LOS of low-variability level 3 and
level 4 patients. Level 5 patients also had an improve-
ment, although the number was too small to be statisti-
cally significant. This study adds evidence to the
effectiveness of “vertical patient flow” models described
in a recent survey of ED medical directors by Liu
et al.,20 which found that 29% had adopted these in
response to the American College of Emergency Physi-
cians Task Force on Boarding.
By placing lower-variability ESI 3 patients in intake,
we decreased the total number of patients going to the
urgent area of the main ED. Decompressing the urgent
area of the main ED, where all level 3 patients were pre-
viously evaluated, predictably resulted in improved LOS
of high-variability level 3 patients treated in this area in
the new process. This result can likely be attributed to
the reduced staff workload and decreased the use of
treatment spaces in this area in the improved process.
1177
-10 0 10
% Difference of Cases
Relative to Controls
Improved flow can affect not only the quantity but
also the quality of care. For example, Sun et al.21
recently found increased LOS, cost, and mortality in a
claims-based review of patients admitted through Cali-
fornia EDs during times of high crowding. Delays in
antibiotic or pain medication administration and
increased errors associated with increased crowding
have also been previously reported.21–24 While this
study did not focus on these outcomes, its presentation
of a possible means to adapt to overcrowding can be
beneficial.25
There was not a significant change in ESI 1 or 2 dis-
charged LOS. While this result is complicated by the
presence of many confounding variables, we believe
that this is due to the very high demand of admitted
patients, resulting in a nursing bottleneck that was not
affected by the process changes. ESI 1 or 2 patients
were typically treated in the emergent area of the ED,
which has the highest number of admissions, the sickest
patients, and little utility for vertical patient flow. Thus
the demand for treatment spaces in this area did not
change as it did in the urgent area of the main ED, and
this may represent a location where crowding as
described by Pines25 is more a result of hospital crowd-
ing than ED processes.
The LOS of ESI 5 patients was likely improved, but
the small sample size prevented us from demonstrating
a statistically significant improvement. Also, our historic
ESI 5 LOS was already quite short, about 1 hour, so to
see a statistically significant improvement may have
required drastic change. In fact, our team anticipated a
potential increase in LOS for ESI 5 patients as these
patients were segmented into our fast track in our his-
torical process, and they would now “compete” with the
low-variability ESI 3 patients for resources in intake. If
our ESI 5 LOS had increased significantly, we would
then have considered treating these patients in an opti-
mized environment such as a “super track.”26
Flow for some diagnoses improved more compared
to others. Throughput times for headache/migraine,
abdominal pain, and sprains were statistically improved
1178
compared to those of open wounds, chest pain, and
back pain. Intake facilitated a standardization of treat-
ment and augmented workflow for some conditions that
was not available before. For instance, abdominal pain
and sprain evaluations typically involve treatment and/
or imaging. In intake, the whole team knew the general
approach even if not the physician’s specific prefer-
ences.
For example, during an abdominal pain or kidney
stone evaluation, the physician would see the patient,
the intake nurse would place the IV, and the technician
would transport the patient to imaging on the way to
the treatment area for IV fluids or medications that the
physician by then would have ordered. The patient
moved to the various processes that, in essence, were
ready and waiting for him or her, rather than the vari-
ous processes finding the patient and completing serial
assessments prior to task completion. We saw improve-
ments for order-to-in-lab times for phlebotomy, and
improvement in order-to-radiology completion for plain
films, as the staff were ready and assigned to those par-
ticular tasks. The intake nurse only performed initial
assessments, gave medications, and gathered diagnos-
tics. The same nurse, when working in the main ED,
would be required to perform the entire nursing task
on the patient, e.g., one patient may require medications
while the other waits for phlebotomy. The approach to
these patients also changed in terms of streamlined
treatment. Traditionally, most patients with abdominal
pain received IV fluids. However, many of these patients
can take fluids by mouth so they do not need IV access,
another opportunity for improved turnaround time.
LOS for diagnoses like open wounds, chest pain, and
back pain improved less, perhaps because they required
more lengthy treatment procedures such as suturing
that could not be overcome by improved transport flow
to imaging. Also, while their evaluations may have been
relatively standard, treatment modalities used may have
had much greater variability so that staff could less suc-
cessfully anticipate providers’ plans.
Further study is needed to assess the relationship
between a resource use–based triage system (ESI) and
diagnoses. While controversial, clinicians may consider
generating consensus for evaluation and treatment of
the most common diagnoses to reduce variability.
LIMITATIONS
We had 10 pilot days over a 3-month period to adjust
and hardwire our process, but the group felt that we
may have still had a learning curve for both nurses and
providers that may have blunted the early results. There
was an initial resistance to placing ESI 3 patients into a
physical area that had formerly been a fast track.
Despite the rollout of the new paradigm, there was dis-
cussion of specific policy stating the ESI 3 patients could
go to this area, and many patients who should have
been ESI 3 were given acuities of ESI 4 until the policy
was changed (Table 3). This may have resulted in a sig-
nificant difference in the ESI distributions between the
study year and the control year. Prior to, and in con-
junction with, this implementation the nurse and physi-
cian staffing were aligned and an improved inventory
Arya et al. • DECREASING LOS WITH SPLIT ESI PATIENT FLOW
and regional supply management plan was created. We
believe that this may have improved the process for
patients going to the main ED, but do not believe this
had a meaningful effect on those patients managed in
intake. Given the retrospective nature of this study, we
acknowledge there may be other unmeasured changes
that influenced the results. However, we do not believe
that there were any other significant process or policy
changes during the study period. Staff were not blinded
during the study; however, this effect may be minimal
due to the retrospective nature of data collection and
the fact that there we were not anticipating publishing
our work. Finally, the discharge times were generated
when each patient was removed from the EMR, and
that was done by the staff soon after the patient left the
ED. This could have artificially increased the patient
LOS. This part of the process was not changed between
the 2 years, and as such we do not believe that it
affected the results.
CONCLUSIONS
The use of a split Emergency Severity Index level 3
triage flow system reduced length of stay for five of the
12 most common ED complaints by 9% to 18% without
increasing length of stay for the most or least ill, despite
a 3.9% increase in overall ED patient volume. Separat-
ing high- and low-variability ESI 3 visits improved
throughput and reduced length of stay in our ED. This
technique is recommended for EDs experiencing exces-
sive length of stay for middle- and low-acuity patients
or those EDs that have bed capacity constraints and
have sufficient volumes to warrant segmentation.
References
1. American Hospital Association. Chartbook: Trends
Affecting Hospitals and Health Systems. Table 3.3
and Chart 3.7. Available at: http://www.aha.org/
research/reports/tw/chartbook/ch3.shtml. Accessed
Sep 6, 2013.
2. Handel D, Epstein S, Khare R, et al. Intervention to
improve the timeliness of emergency care. Acad
Emerg Med. 2011; 18:1295–302.
3. Ward MJ, Farley J, Khare RK, et al. Achieving
efficiency in crowded emergency departments: a
research agenda. Acad Emerg Med. 2011; 18:1303–
12.
4. American College of Emergency Physicians. Policy
statement. Triage scale standardization. Ann Emerg
Med. 2004; 43:154.
5. Mchugh M, Tanabe P, McClelland M, Kahre RK.
More patients are triaged using the emergency
severity index than any other triage acuity system in
the United States. Acad Emerg Med. 2012; 19:106–9.
6. Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy
N. Reliability and validity of a new five-level triage
instrument. Acad Emerg Med. 2000; 7:236–42.
7. Harris M, Wood J. Resuscitate ED metrics with
split-flow design. Healthc Financ Manage. 2012;
66:76–9.
8. Considine J, Kropman M, Kelly E, Winter C. Effect
of emergency department fast track on emergency
ACADEMIC EMERGENCY MEDICINE • November 2013, Vol. 20, No. 11 • www.aemj.org
department length of stay: a case-control study.
Emerg Med J. 2008; 25:815–19.
9. Sanchez M, Smally AJ, Grant RJ, Jacobs LM. Effects
of a fast-track area on emergency department per-
formance. J Emerg Med. 2006; 31:117–20.
10. Soremekun AO, Terwiesch C, Pines JM. Emergency
medicine: an operations management view. Acad
Emerg Med. 2011; 18:1262–8.
11. Institute of Medicine. Hospital-based Emergency
Care: At the Breaking Point. Washington, DC:
National Academies Press, 2006.
12. Singer AJ, Thode HC Jr, Viccellio P, Pines JM. The
association between length of emergency depart-
ment boarding and mortality. Acad Emerg Med.
2011; 18:1324–9.
13. McCarthy ML, Zeger SL, Ding R, et al. Crowding
delays treatment and lengthens emergency depart-
ment length of stay, even among high acuity
patients. Ann Emerg Med. 2009; 54:492–503.
14. Pines JM, Luyer S, Disbot M, Hollander JE, Shofer
FS, Datner EM. The effect of emergency department
crowding on patient satisfaction for admitted
patients. Acad Emerg Med. 2008; 15:825–31.
15. Pines JM, Pollack CV Jr, Diercks DB, Chang AM,
Shofer FS, Hollander JE. The association between
emergency department crowding and adverse car-
diovascular outcomes in patients with chest pain.
Acad Emerg Med. 2009; 16:617–25.
16. Bernstein SL, Aronsky D, Duseja R, et al. The effect
of emergency department crowding on clinically
oriented outcomes. Acad Emerg Med. 2009; 16:1–10.
17. Welch SJ, Stone-Griffith S, Asplin B, et al. Emer-
gency department operations dictionary: results of
1179
the second performance measures and benchmark-
ing summit. Acad Emerg Med. 2011; 18:539–44.
18. Langley R. The Improvement Guide. Hoboken, NJ:
Wiley, 2009.
19. Agency for Healthcare Research and Quality.
Healthcare Cost and Utilization Project Tools and
Software. Available at: http://www.hcup-us.ahrq.
gov/tools_software.jsp. Accessed Sep 6, 2013.
20. Liu SW, Hamedani AG, Brown DF, Asplin B, Cam-
argo CA Jr. Established and novel initiatives to
reduce crowding in emergency departments. West J
Emerg Med. 2013; 14:85–9.
21. Sun BC, Hsia RY, Weiss RE, et al. Effect of emer-
gency department crowding on outcomes of admit-
ted patients. Ann Emerg Med. 2013; 6:605–11.
22. Pines JM, Localio AR, Hollander JE, et al. The
impact of emergency department crowding
measures on time to antibiotics for patients with
community-acquired pneumonia. Ann Emerg Med.
2007; 50:510–6.
23. Pines JM, Hollander JE. Emergency department
crowding is associated with poor care for patients
with severe pain. Ann Emerg Med. 2008; 51:1–5.
24. Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula
KH. ED overcrowding is associated with an
increased frequency of medication errors. Am J
Emerg Med. 2010; 28:304–9.
25. Pines JM. Emergency department crowding in Cali-
fornia, a silent killer? Ann Emerg Med. 2013;
61:612–4.
26. Crane J, Noon C. The Definitive Guide to Emer-
gency Department Operational Improvement. Boca
Raton, FL: CRC Press, 2011.