A Geographical based care model ZoningWhere patients within a specific geographical space in

A. Geographical based care model: (Zoning)Where patients within a specific geographical space in the emergency Department with certain number of beds are assigned to specific providers (physicians and nurses).This model is often based on 4 beds per nurse, with two nurses per physician, so each physician cares for a total of 8 beds at a time (may include a scribe and/or tech). At one suburban community hospital, a team assignment system was implemented with each team consisting of one physician, two nurses, and one tech. The teams were assigned specific rooms, though the study did not mention if these were located in geographic zones or random throughout the department. After implementation, the average time to physician evaluation went from 71.3 minutes to 61.8 minutes. Other metrics that improved after the team assignment method was adopted included left without being seen rate (decreased from 2.3% to 1.6%), patients seen by a physician within 1 hour (increased from 56.3% to 64.0%), and patients who waited >3 hours for physician assessment (decreased from 17.8% to 11.8%). Across the board, the team assignment system was associated lower wait times for patients to have initial evaluation by a physician and fewer patients who left without being seen.(24) Another ED trialed a team-based approach a PDSA-cycle to implement the intervention. Two teams were created, each grouped a senior doctor with several residents and nurses. The two teams were assigned to work in the critical area of the department, but the study did not specifically describe if the teams were assigned to specifically zoned rooms within the area. Patients were triaged and assigned in an alternating manner to fairly spread the workload throughout the department. Specifically, this ED had found that residents often consulted senior physicians only late in the treatment plan, which caused additional time to be wasted in altering the plan and adding tests/treatments. They hoped to limit this by establishing more consistent communication through the team approach. Analysis was done for 32,420 patients over one and a half years. The average wait time to physician consultation (WTC) had been 162 minutes, which decreased to 114 minutes after the team-based approach was implemented. Additionally, staff feedback was reported as “uniformly positive” due to improved efficiency and transparency of communication.(25)A similar program was implemented at a large emergency department in California. A zone system was implemented and the 45-bed ED was divided into 5 units, each staffed with one EM physician, three nurses, and one tech. This team remained stable throughout the physician’s shift. One of the nurses in each zone functioned as a team coordinator and controlled the patient flow within the zone. Each patient was assigned a zone at triage so that the waiting room was unofficially split into five separate areas that corresponded to the five zone. As part of this program, physicians were also required to do a medical screen of all patients within one hour of their arrival, allowing for tests and treatment to be initiated from the waiting room. The results of this study showed average decrease in time from arrival to physician evaluation from 74 minutes to 39 minutes and median length of stay time decreased to 78 minutes. Additionally, patient satisfaction improved 51% within two months. (34)Same concept was applied at the University of Tennessee Medical Center in Knoxville, 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.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.This model allows an effective communication, which includes face-to-face conversations, telephone conversations and the entry of text into a medical record & this is essential to successful teamwork and fundamental to high-quality patient care (26) The main identified teamwork obstacles were workforce shortage, frequent changes, fatigue, and lack of competency, motivation, assertiveness, and information sharing system. (27)

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