“We took a look at that arrival workflow and got very granular in terms of looking at why it doesn't work very well. We developed this specific workflow to get these patients in front of the providers as quickly as possible,” he said. “The quicker we can get the providers in front of the patients, the quicker the workups start, and hopefully the quicker we can get them out of the ED.”

Park said that if you look at it form the patient's perspective, they come in, they register, and they wait, and then they go into triage and talk to a nurse. They have to answer a bunch of questions and then they wait some more. Then if they're lucky they get roomed. But if there are no rooms, they wait longer. “Sometimes they wait hours before they see a provider,” he added. “That’s the traditional model. We decided to flip that whole script upside down and front-load the triage nurse and the virtual provider at the same time virtually, so that we can do that whole process in parallel instead of just one after the other.” 

All that waiting in between those steps is wasted time, Park stressed. It's time that we could use to actually provide care. “So we decided to integrate virtual nursing because it fit into our model. If we do things in parallel, things get done a little bit faster, and it's been working really well. I think the real innovation behind that is that everything is getting done in parallel. They might still be waiting for a room but they are getting care. They're getting the blood tests, the X-rays, while they're waiting, so that if they even need to see a provider in the back, once they see them, all the results are back.”

Park spoke about the challenges of scaling up the model from Charleston to other emergency departments in the health system. He noted that all of the EDs have different cultures, staffing, and constraints. The MUSC Health team had to customize this new model to those teams.

“Before we launch, the on-site team and the virtual team have time to get to know each other,” Park said. One of the first things they did was create a secure chat within Epic that serves as a communication pipeline throughout the day. “When a provider first checks in and a virtual nurse first checks in, we do a huddle with the on-site team so that we have a communication pipeline where we can escalate things and talk about patients that need certain tests and what we're worried about,” he said. The on-site team and the virtual team are always on the same page for every single patient.

Another key to success is ownership of tasks. “In order for this to work, the ground team and the virtual team have to have separate tasks, and it needs to be explicitly stated that a certain team owns that task so that we can work as a team without having to prompt each other," Park said. 

Currently, they have the Pee Dee market, the Orangeburg market, and the Charleston market and “hopefully we're going to be expanding it soon to the Catawba and the Upstate market as well,” Park said. 

“We have seen a significant reduction in the door-to-provider time, as well as a reduction in total length of stay,” Bartman said. “Obviously, if you come in and workup starts relatively quickly, you're not waiting for hours to be seen.”

Park said this work also has had an impact on the overall patient experience. It is redefining the lobby as the the new treatment space, where they are getting the workup started. “Any patient who waits for more than 30 minutes in the the lobby, it’s very difficult to recover from that negative impression of that period while in the lobby,” he added. “But we have created an NPS [Net Promoter Score] survey for our patients, and we had fantastic results. I believe our NPS score was about 80. All of the work we've done on the front end not only has improved all the normal ED metrics, but also has made a significant impact on the overall patient experience.”