Physician-driven early evaluation: Encounters seen in a vertical model

Background

Although many emergency departments (EDs) employ some form of vertical patient flow, there is limited published literature describing variations of vertical pathways.

Objectives

We sought to describe our ED's emergency physician (EP)-driven vertical model and to characterize patients selected by EPs to be seen in our vertical space.

Methods

We retrospectively reviewed all vertical ED encounters in the study period, separately analyzing those who eventually received an ED bed (“ED Bed”) and those who were discharged without being roomed (“Vertical only”). We report patient demographics, ESI, vital signs, oxygen use, chief complaints, resource utilization, ED LOS, disposition, and 72 ​h return rates.

Results

Physicians elected to perform initial evaluations of a variety of patients in the vertical space. The two most common classes of complaints evaluated in the vertical space were extremity issues (21.4%) and skin complaints (13.5%). Patients presenting with abdominal pain and chest pain initially assessed in vertical were significantly more likely to later receive an ED bed (Standardized Difference of 38% and 21.4% respectively), and patients with skin complaints were more frequently discharged from the vertical space and were less likely to receive an ED bed (Standardized Difference of 32.2%). Most (56.2%) Vertical only patients were ESI 3, although EPs also discharged ESI 2, 4, and 5 patients from Vertical.

Conclusions

EP-driven patient selection for a vertical pathway allowed EPs to discharge some patients without bed placement while simultaneously functioning as their own triage physicians for higher-acuity patients who would go on to receive an ED bed.