An Emergency Department PCAT Model:
The HOT ZONE
The HOT ZONE was a project our team discussed but never had the opportunity to trial. This was an Emergency Department process improvement initiative. The primary idea was to develop a parallel, team-based process for evaluation of ED patients similar to the PCAT process discussed earlier.
Many Emergency Departments provide a type of rapid triage when patients enter the ED via walk-in. This is often referred to as “Provider in Triage” and consists of a Physician or APP providing a rapid assessment of the patient, a cursory exam, and the ordering of tests or initiation of treatment if deemed appropriate. This might include ordering blood work, an x-ray or providing Tylenol for a fever. The purpose of provider in triage was to expedite the evaluation of patients in a timelier manner to reduce overall throughput time. The idea has merit and I can attest to this as I did a two-week trial of provider in triage at one hospital I worked at. I will say that it was grueling 12-h shifts that were virtually non-stop running from 10 am to 10 pm averaging 65 patients seen each shift. The benefit was approximately 18 patients per day were discharged from triage to home. I had 3 rooms, 2 nurses, and a tech during the 12 h.
There is a downside to provider in triage.
- (1) Patients evaluated were all walk-ins
- (2) There were limitations on what could be ordered test wise
- (3) If individuals doing provider in triage did not particularly like it, they would simply send the patient into the ED proper
- (4) If not skilled, you could get seriously behind triaging on a busy day
(5) Some ED providers would get upset because either tests were ordered or they felt the tests ordered were insufficient to evaluate the patient’s problem
The HOT ZONE concept took a different approach.
We wanted the “HOT ZONE” to evaluate all acute patients entering the ED regardless of portal of entry. Ambulance delivery, walk-in. or drop-offs would all be seen in the HOT ZONE. The HOT ZONE was to be an allocated number of beds using a team-based approach for patient evaluations during the busiest periods of ED activity.
Currently, most ED Physicians see on average 1.8 patients per h in the ED. There may be some who see more, or some see less but that is the average. The amount of time an ED provider actually spends with a patient is relatively brief. On average, this is about 8 min. The goal for the HOT ZONE was to design a system that would allow the provider to see over 4 patients per hour. In order to do this, it required the following team members in a 4 bed HOT ZONE—Physician, Nurse, Scribe, Tech, available Respiratory therapist, and Registrar.
The HOT ZONE size will be dependent on the team removing patients quickly after the patient’s initial assessment and workup. In the beginning, the maximum time a patient could remain in the HOT ZONE would be 1 h. The patients coming to this zone will have had minimal if any evaluation. Triage would be direct to the zone, rapid registration would be done in the zone, and the ED provider would evaluate and determine testing needs and highest probability disorder in very short order. Lab work would be acquired, EKG, vital signs, and placement of IV and fluids if indicated. Initial treatment would be initiated and if necessary, a patient may require intubation or cardioversion. The only patients not placed here would be patients in acute cardiac arrest; they would be placed in the trauma room because the time allocation could bring the HOT ZONE to a screeching halt.
The key component of this concept was getting all other hospital resources to be active participants. Patients requiring the ICU needed to leave in 1 h, patients requiring an acute procedure like cardiac catheterization needed to leave in 1 h and so on. In addition, once a patient no longer required placement in the HOT ZONE, they would be handed off to another provider. If remaining in the ED, the patient would be handed off to an APP. If the patient clearly required hospital admission, they would be handed off to the receiving hospi- talist attending.
The purpose was to take advantage of the unique skill sets of an Emergency Department Physician-Resuscitate-Evaluate- Treat-Disposition. There were many unanswered questions by the team about the concept and how it would function. It clearly required a set volume of patients being evaluated each hour in order to be cost effective and functional. So, this idea might not be usable for very small EDs that see 20 or 30 patients daily and for large EDs may require more than one team to manage the higher volume. Perhaps someone will put the concept to the test in the future.