How We Implemented A Split Flow Hallway

Emergency department (ED) hallway spaces (HS) are frequently used during overcrowding, exposing patients to safety, privacy, and equity risks. While vertical split flow (VSF) improves throughput, safety-focused hallway interventions are underreported. At Duke University Hospital (DUH) ED, increasing patient volume and acuity resulted in frequent HS use as active treatment areas. Safety reports identified critically ill patients being triaged to or deteriorating within HS due to inconsistent processes and oversight.

A multidisciplinary workgroup implemented standardized HS workflows through iterative Plan-Do-Study-Act cycles. Interventions included standardized staffing, patient selection criteria, remote monitoring, privacy enhancements, and application of VSF principles to hallway operations.

A retrospective analysis of adult patient acuity and disposition for 11,602 HS encounters over 53 weeks evaluated the effect of the interventions. The DUH Institutional Review Board determined this activity did not meet the definition of research.

Patients in vertical HS were less likely to be high-acuity (incidence rate ratios [IRR] 0.68, 95% CI 0.65-0.71) and less likely to be admitted (IRR 0.30, 95% CI 0.27-0.33) than those in horizontal HS. No HS-related safety reports occurred during the intervention.

Standardized hallway workflows and patient selection criteria safely operationalized HS for continuous use, reducing exposure of high-acuity patients to hallway care.