A stream for complex, ambulant patients reduces crowding in an emergency department

The study aims to evaluate the effect of adding a stream for complex, ambulatory patients in an ED.

The setting was an ED in a principal referral hospital in New South Wales, Australia. In 2011, a new stream was added to the pre-existing acute care (high complexity patients) and fast track (low complexity patients) streams. Space in acute care was set aside for the purpose of assessing patients who would previously have been assigned to acute care and who were capable of sitting in a chair with limited nursing care. The stream was separately resourced with staff redeployed from acute care. Early involvement of an emergency physician was a core characteristic of the process. Two 13 week periods before and after the intervention were compared.

Presentations increased by 8.2%. Forty-three per cent of patients were triaged to the new stream. The median ED length of stay fell from 327 (interquartile range [IQR] 192-527) min to 267 (IQR 163-412) min (P < 0.001), the average daily occupancy of the department fell from 38.1 patients to 34.9 patients (95% confidence interval [CI] for difference 1.6-4.8, P < 0.001) and the proportion of patients who did not wait to be seen fell from 12% to 5.6% (95% CI for difference 5.8-7.1, P < 0.001).

The use of an appropriately resourced stream directed towards seeing a complex group of patients who do not require ongoing nursing care and who are capable of sitting in a chair improved departmental flow.