Best Practices: Vertical Patient Flow and ED Overcrowding

Although emergency department overcrowding has been recognized as a significant problem for both EDs and the hospitals in which they function, some progress has been made to address this trend. ED overcrowding continues to disproportionately burden academic and urban medical centers. Not surprisingly, some of the major innovative approaches being utilized to address overcrowding are coming from these environments. We will focus on ACEPs Task Force on Boarding’s recent recommendations to improve patient flow.1

In their recent article on novel approaches to overcrowding in the ED setting, Liu, Hamedani, et al. define vertical patient flow as the redesign of front and operations in the emergency department to better increase patient flow, throughput, and satisfaction.2 Some of the key changes seen in departments that have implemented vertical patient flow designs include bedding a patient immediately without triage first, having a provider in triage to immediately assess any patient presenting to the ED, removing waiting rooms completely, and redefining the concept of triage. Each of these changes has significant pros and cons but more importantly, implementing these changes require significant political and colleague buy-in for effective implementation.3

Bedding of patients before triage and registration allows a provider to see a patient immediately, get the work-up started, and cut time off their length of stay.  In instances where cases are minor, treatment and discharge can occur very rapidly.  This approach is the basis for fast-track models already in existence and often times the biggest impediment to rapid patient turnover is the time it takes to finish triaging the patient. Utilizing this approach requires a fundamental change in what we believe we are supposed to be doing in the emergency department. Like other over bloated bureaucracies, we sometimes do things out of habit, rather than necessity, and challenging the orthodoxy is the equivalent of heresy. To implement these changes, all parties need to be committed to the mission: getting patient in and out quickly and safely.

Along these lines, having a provider (physician/PA/NP) in triage itself, evaluating patients as they present to be seen, allows for rapid screening, diagnosis and discharge of minor complaints so that they never even need to occupy an acute-care bed. Akin to the Fast-Track model issues however, if the system is designed so that after every fiefdom has to do their redundant parts, this will only muddy patient flow, lead to resentment amongst the various professionals involved with caring for the patient, and ultimately be counterproductive. This approach, if utilized effectively, is a potent way of keeping acute care beds available for those who truly need them.

Some hospitals have taken the bold step to completely remove “waiting rooms” and in the process have created the illusion that all patients are seen immediately. In reality this may be the case that patients are indeed seen faster, but it's important from a systems perspective to not just get people sitting in chairs awaiting lab results or other medical testing that's time-dependent, for the sake of creating the illusion of “no waiting.”  Increased infrastructure needs to be in place to absorb the ebbs and flows of patient load, and by utilizing this approach the bottom line of EM budgets can be severely impacted.

Ultimately, good vertical patient flow will likely utilize several of the above approaches to decrease wait times and improve access to care. Is there a major commitment on the parts of providers, nursing, administration, facilities, and the patients themselves? Patients have been conditioned to believe that long waits are inevitable in the ED setting, and when implementing these changes their suspicions will need to be allied. Once done, once patients start believing again that they will be seen in a timely manner, we will start to see the rewards on our end—better patient satisfaction scores, better provider satisfaction, and better patient care.

Gregory Raines, MMSc, PA-C, President, SEMPA


1. ACEP Boarding Task Force Emergency Department Crowding: High-Impact Solutions. Available at: Accessed May 14, 2013.

2. Liu S, Hamedani, A, Brown, D, et al. Established and novel initiatives to reduce crowding in emergency departments. West J Emerg Med. 2013; 14(2): 85-89.

3. Wiler JL, Gentle C, Halfpenny JM, et al. Optimizing emergency department front-end operations. Ann Emerg Med. 2010;55:142–160.