Integrating EMS with Emergency Room Triage and Patient Flow (Split Flow ER)

Integrating EMS with Emergency Room Triage and Patient Flow (Split Flow ER)

Per the CDC, there are over 130 million visits to the Emergency Room in the United States annually.  About 12.2 million of those are admitted and 1.5 million are critical care patients. https://www.cdc.gov/nchs/fastats/emergency-department.htm

***03/14/17 Update:  SLH, VBGH and now SPAH are all using a pivot nurse in triage and a split flow concept.  I have confirmed the following items with each facility:

  • You may be sent to triage more often
  • You should wait for a reasonable amount of time in line with the patient to give a brief turn over to the pivot nurse.  Reasonable depends on the line and the your call volume.  If you can no longer wait, advise the patient to keep waiting and give the charge nurse in the back any important information that you feel needs to be passed along.
  • If the patient needs a wheelchair (if they can’t stand or are frail), please transition them to the chair in the back of the ED-not in triage.  They have asked not to automatically put everyone in a wheelchair unless it is needed.***

It used to be that patients were triaged and sent to an ER bed.  As the acuity levels changed and waiting rooms got fuller, many ER’s opted to have a minor care area where they could cycle minor injuries and illnesses through faster.  As patient counts continued to increase, they embraced a new concept called split flow.  Each facility has their own variation based on space and needs.  The patients enter the ER, are quickly checked by medical staff and “pivoted” to determine their severity of illness or injury.  The patients may be taken directly to a room or go through a more traditional triage process.  There is a doctor or advanced care provider who starts tests and orders while being triaged.

After triage, the patients who aren’t “really sick” may need a brief evaluation and can quickly be sent home or may need some further testing or treatments.  Most of these patients do not require a bed for their stay.  They may have chairs or loungers in a separate area for the patients waiting on test results or stitches.  You can think of it as a doctor’s office, urgent care center and ED all rolled into one. Both Sentara Leigh and Sentara Virginia Beach General have started a split flow concept.

This means that instead of always going directly to a bed in the back, you may be directed to triage more often.  We have all transported the patient who should really go to their doctor or urgent care instead of requesting an ambulance.  The same patient doesn’t need to take up a bed in the ER if it isn’t necessary.  The patient can be cycled through the proper section/area which reduces wait times and increases bed space.  Here are a few items for consideration:

  • When you call in your report, the charge nurse may ask extra questions such as, is the patient ambulatory. If the patient is not able to sit in a wheelchair or walk, please let them know.
  • If you feel the patient may only need a minor care or fast track style exam, please feel free to suggest that your patient is a candidate for triage. But keep in mind, the charge nurse may want to see the patient prior to making a decision on where to send them.
  • If your patient is sent to triage, please have them get off of your stretcher and into a wheelchair in the back (ER) not in the waiting room.
  • If your patient has any changes in status or you learn something new about their condition, please make sure you advise the charge nurse via radio or on arrival.
  • When taking a patient to triage, you do not need to give a verbal turnover directly to the triage staff. You may place them in line with the other waiting patients or walk them directly to the pivot nurse for a hand off if there is no line.  They do not require much more than a hand off unless there is something urgent. Registration should take less than two minutes per patient so waiting for a hospital sticker should still take less time than waiting for a bed!
  • If you have a concern about where the patient is directed, please consult the charge nurse.