The ED team model assigns a team of providers to a certain number of beds in a small geographic area of the department, allowing for increased collaboration among caregivers, improved overall efficiency and better patient satisfaction.
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At some point, most hospital emergency departments, particularly EDs with high patient volumes, struggle with patient flow and efficiency. These hospitals may experience problems such as long wait times, large numbers of patients leaving the hospital without treatment, extended lengths of stay and low satisfaction among patients and providers.
One model that can alleviate these problems is an ED team model of care, also commonly referred to as a "zone" or "pod" model. This structure assigns a team of providers to a certain number of beds in a small geographic area of the department, allowing for increased collaboration among caregivers, improved overall efficiency and better patient satisfaction.
ED flow challenges
EDs that do not use a team structure typically face several common challenges. To illustrate those challenges, consider an ED that has two physicians and a number of nurses who cover about 20 patient rooms. As patients come into the ED, the physicians see each patient in the next available room.
In this scenario, at any given time, one physician may have patients in rooms 1, 5, 10, 17 and 20. To treat those patients, the physician must cover a large span of the department. A spaghetti diagram of his or her steps would show the physician walking all over the ED. All of this travel consumes valuable time that the physician otherwise could spend at the bedside or performing other important tasks.
In turn, it increases patients' lengths of stay — much of which may be spent waiting around for the physician to return. Additionally, because nursing teams are typically assigned to a cluster of adjacent rooms, this ED physician also ends up working with most or all of the nurses in the department at the same time. This reduces the likelihood that the physician and nurses can develop the collaboration and teamwork necessary for optimal efficiency.
Another potential pitfall of this model is physician selectivity of patients. Because there is no clear designation of which patients go to which physician, one physician may try to avoid particularly difficult cases in hopes that a colleague will take them, leaving some patients waiting longer for care. And another physician may try to treat too many patients or take all the high-acuity cases, slowing down his or her workflow. Again, the result can be longer wait times, longer lengths of stay and low satisfaction.
The team model
The ED team model offers a different way of distributing the workload within the ED to help improve patient flow and satisfaction. In a common team structure, one physician will be assigned to a group of adjacent rooms where he or she works with the same team of nurses for the entire shift. An ED using this model will likely have multiple teams in operation, with each team seeing patients of a certain acuity level.
For example, at the University of Tennessee Medical Center in Knoxville, Tenn., the Level I trauma center ED is structured around seven different teams — two for the most acute patients, two for sub-acute patients and three that are staffed by advanced practice clinicians to handle patients with urgent-care needs. When patients check into the ED, they are assigned to a particular team based on acuity. That assignment takes patients to a smaller waiting area for that team or directly into a bed.
Team benefits
By segmenting the ED into smaller teams, most departments experience significant improvements in efficiency and satisfaction.
For physicians and nurses, having a fixed team and group of beds cuts down on foot traffic around the department. Working in one zone, providers can better collaborate to treat patients more quickly, which results in shorter wait times, shorter lengths of stay and a reduced number of patients who leave without receiving treatment. Providers in a team also tend to learn each other's practice patterns and style, which lets them work together more efficiently. Using a team model, University of Tennessee Medical Center providers can see patients faster, get their orders in faster, and more quickly arrive at a decision to discharge or admit a patient.
In addition to the shorter wait times and lengths of stay, patients also tend to feel they are getting faster and more personalized care in a team environment. Patients often see their physician and nurse at the same time for the initial evaluation, and providers can check on patients frequently because of their close proximity. This streamlines workflow and helps the patient feel like all providers are working together and giving the appropriate time and attention to his or her condition, helping to bolster satisfaction.
Successful implementation
When a team model is implemented properly, physicians and nurses experience increased satisfaction, as well. Providers tend to like the stability of collaborating with a familiar team where they know each other's practice patterns and can work together most productively.
Instituting a team model for the first time, however, requires a delicate approach. Before making any changes, it's important to help physicians understand not just the "what" of the workflow changes, but also the "why." That is, hospital and department leaders must explain how the team model will benefit the physician in his or her daily workflow, how it will boost satisfaction for patients and how it will help the department run more smoothly.
Also critically important is making sure the person in charge of steering patients to the appropriate team is well-trained and effective in the role. In order for the team model to function properly, this non-physician must correctly assign patients to the appropriate team while ensuring a relatively even workload across the department. Otherwise providers and patients may experience the frustrations of patient backlogs or wait times, even with a team approach.
Conclusion
Achieving efficient patient flow in the ED is challenging for many hospitals. Without a strong system in place, the department may face long wait times and lengths of stay, a high number of patients who leave without treatment, and poor satisfaction among patients and providers. Implementing a team model of care in the ED can help hospitals overcome these challenges and achieve a more efficient workflow that benefits patients, providers and the hospital.
Joseph Spinell, DO, is the TeamHealth Emergency Department Medical Director at University of Tennessee Medical Center in Knoxville, Tenn.