Mid-Track Process Flow Chart

Goal:
Expedite the care of the Emergency Severity Index (ESI) III patients by effectuating a reduction left without being seen rates and overall time to provider.

Innovation:
A new service model that segments ESI III patients at triage into a designated area with dedicated staff, the goal being to provide an environment geared towards treating those types of patients and making better use of resources.

Result:
The overall left without being seen rate (LWBS) decreased from 2.6% to 1.9%. Specifically, the LWBS rate among ESI III patients dropped from 4.9% to 3.1%. The LWBS rate of MidTrack patients dropped from 7% to 3.9%.

Institution:
Good Samaritan Hospital Medical Center
1000 Montauk Highway
West Islip, NY 11795
P: (631) 376-3000

From the expert:
“The MidTrack is a necessary service function in the Emergency Department (ED), allowing us to deliver timely care to these types of patients who are statistically more prone to leave but then return in worse shape. We think it is truly a model of how most EDs will be organized in the future.”

Adhi Sharma
Emergency Department Medical Director
Good Samaritan Hospital Medical Center

Profile:
Location: Suffolk County, NY
Number of emergency department visits annually: Approximately 100,000
Number of beds: 437
Ownership: Non-profit, Catholic Health Services of Long Island
Affiliations: Mount Sinai Hospital and Mount Sinai School of Medicine
Teach status: Yes

Good Samaritan Hospital Medical Center is a 437-bed Magnet Designated not-for-profit hospital serving patients on the south shore community of Long Island that receives over 100,000 annual ED visits.

Clinical areas affected:

  • Emergency department
  • Ambulatory Surgery Unit
  • Radiology

Staff involved:

  • Physicians
  • Non-physician providers
  • Nurses
  • Technicians

Timeline:
Preparation and planning for implementation of the MidTrack process took approximately six months to achieve before going live, but Good Samaritan expects it can be done in a shorter time period following their learnings.

Contact:
Adhi Sharma, M.D., F.A.C.E.P., F.A.C.M.T.
Chair, Emergency Medicine
P: (631) 376-4094
GoodSamED@chsli.org

Innovation Implementation:
Like many hospitals across the country, Good Samaritan Hospital Medical Center has long been looking for strategies to improve throughput rates and reduce crowding in their ED. During times of peak census, patients may experience long wait times and dissatisfaction which inevitably lead patients to leave without being seen.

Recognizing the significant potential for high morbidity associated with mid-acuity patients who leave prior to being seen, the hospital chose to develop a solution to address this problem. Similar to a Fast Track protocol—where patients with minor medical emergencies receive prompt treatment and are released relatively quickly—the goal of the MidTrack is improving how the ED cares for the mid-acuity (ESI level III triage category) patients. Patients affected by this system are those triaged to category ESI III with one of the six more common ESI III complaints—abdominal pain, flank pain, headache, pregnancy-related complaints, vaginal bleeding or vomiting.

Under the MidTrack system, a physician is dedicated to manage the diagnostic phase for these patients immediately after their triage. Patients are treated in the Ambulatory Surgery Unit (ASU) space located directly over the ED; their care is directed by that same physician and coordinated by nurse practitioners. Focus was placed on this group, as they are too complex for a typical fast track, but not so ill that they need to be seen immediately, during times of peak census. Experience has demonstrated that this mid level severity group have significant potential for morbidity and are at increased risk when they leave without being seen.

In the MidTrack area the selected patients can be given more dedicated and timely attention in an environment geared towards treating their illnesses. It optimizes ED resources and ensures that these patients are monitored closely.

To date, the strategy has been successful and, if remaining effective, Good Samaritan hopes that it will have larger implications for future ED redesign at hospitals everywhere.

Advice and lessons learned:

  1. Choose the triage physician carefully. This project could hinge on who you pick to serve as your triage physician, so think about the qualities that would allow someone to succeed in this role. They shouldn’t order every test on every patient, but they shouldn’t be a minimalist either.
  2. Be vigilant about maintaining proper supplies. Good Samaritan found that improper stocking of supplies, created inefficient work flows for nurses. Determining proper supplies and par levels are critical for a successful implementation.
  3. Promote ambulatory patients. Good Samaritan advises putting patients in recliners, rather than in stretchers in order to keep things moving. It promotes a dynamic environment.
  4. Keep dedicated technicians nearby. Due to the increased number of diagnostic tests that ESI III patients typically need, the hospital found that having the additional, dedicated technician nearby was critical, and their implementation would have likely suffered without it.


Cost/benefit estimate:
Implementing the MidTrack process required reallocation of unused space near the ED and one dedicated full-time staff member, at a minimum. In addition to the improved quality of care provided, these costs are minimal when compared to the potential revenue gain realized by significantly reducing the number of patients who leave without being seen and the associated revenue that leaves with them.

Tools to Download:

  • MidTrack Evaluation Form
  • MidTrack Flow Chart