ORIGINAL CONTRIBUTION

The Effect of an Emergency Department

Dedicated Midtrack Area on Patient Flow
Olanrewaju A. Soremekun, MD, MBA, Frances S. Shofer, PhD, David Grasso, MD,
Angela M. Mills, MD, Jessica Moore, RN, and Elizabeth M. Datner, MD

Abstract
Background: Emergency department (ED) crowding negatively affects quality of care and
disproportionately affects medium-acuity (Emergency Severity Index [ESI] level 3) patients. The effect of a
dedicated area in the ED focused on these patients has not been well studied.
Objectives: The objective was to find out the operational effect of a midtrack area dedicated to the
evaluation and safe disposition of uncomplicated medium-acuity (ESI 3) patients.
Methods: This was a 24-month pre-/postintervention study to evaluate the effect of implementation of a
dedicated midtrack area at an urban tertiary academic adult ED. The midtrack had three examination
rooms and three hallway stretchers for ongoing treatment staffed by an attending physician and two
registered nurses (RNs). Besides the two additional RNs representing a 3.4% increase in total daily
nursing hours, the intervention required no additional ED resources. The midtrack area was open from 1
p.m. to 9 p.m. on weekdays, corresponding to peak ED arrival rates. All patients presenting during
weekdays were included, excluding patients triaged directly to the trauma bay or psychiatric unit or who
expired in the ED. The main outcomes were left without being seen (LWBS) rates and ED length of stay
(LOS), adjusting for patient volume, daily total patient hours (a proxy for ED crowding), and acuity.
Results: A total of 91,903 patients were included for analysis during the study period including 261 pre-
and 256 postintervention days. Comparing the pre- and postintervention periods, mean ED daily visits
(173 vs. 182) and mean total daily patient hours (889 vs. 942) were all significantly higher in the
postintervention period (p < 0.0001). There was no significant change in percentage of patients with high
triage acuity levels. Despite this increase in volume and crowding, the unadjusted and adjusted LWBS
rates decreased from 6.85% to 4.46% (p < 0.0001) and from 7.33% to 3.97% (p < 0.0001), respectively. The
mean LOS for medium-acuity patients also decreased by 39.2 minutes (p < 0.0001). For high-acuity
patients, there was no significant change in the mean time to room (14.69 minutes vs. 15.21 minutes,
p = 0.07); however, their mean LOS increased by 24 minutes (331 minutes vs. 355 minutes, p < 0.0001).
Conclusions: Implementation of a midtrack area dedicated to caring for uncomplicated medium-acuity
(ESI 3) patients was associated with a decrease in overall ED LWBS rates and ED LOS for medium-
acuity patients.
ACADEMIC EMERGENCY MEDICINE 2014;21:434–439 © 2014 by the Society for Academic Emergency
Medicine

E
mergency department (ED) crowding has been
steadily increasing over time and has been
shown to negatively affect several domains of
quality such as timeliness, safety, and patient-centered-
ness.1–4 Given the high prevalence and negative effect
on quality, ED crowding has been recognized as an
important public health issue, leading to the inclusion of
ED crowding metrics in the 2013 Centers for Medicare
and Medicaid Services (CMS) hospital reporting guide-
lines.5 Various interventions have been studied to allevi-
ate ED crowding. ED-level interventions such as
bedside registration, immediate bedding, and placement
of a physician in triage have been successful in improv-
ing patient flow.2,6–8 Other interventions such as dedi-
cated fast-track areas, usually staffed by midlevel
providers, have also been shown to decrease wait times

From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA.

Received July 21, 2013; revisions received October 7 and November 4, 2013; accepted November 7, 2013.
Presented at the American College of Emergency Physicians Scientific Assembly, Denver, CO, October 2012.
The authors have no relevant financial information or potential conflicts of interest to disclose.
Supervising Editor: Richard T. Griffey, MD, MPH.
Address for correspondence and reprints: Olan A. Soremekun, MD, MBA; e-mail: olanmd@gmail.com.

ISSN 1069-6563 © 2014 by the Society for Academic Emergency Medicine

434 PII ISSN 1069-6563583 doi: 10.1111/acem.12345
ACADEMIC EMERGENCY MEDICINE • April 2014, Vol. 21, No. 4 • www.aemj.org
and length of stay (LOS) for the lowest-acuity ED
patients.9,10
Given the high prevalence of dedicated fast-track
areas and the ability of EDs to create treatment space
for the highest-acuity patient even during high levels of
crowding, the groups of patients who have the longest
wait times are the medium-acuity Emergency Severity
Index (ESI) level 3 patients.11,12 Based on acuity or
resources required, these patients cannot be cared for
in most fast-track areas and are often placed lower in
priority for regular ED beds.
These medium-acuity patients may vary widely in
terms of resources needed, complexity, and need for ED
beds. A subset of these patients may need relatively few
resources. A dedicated area of the ED focused on the
identification and disposition of this subset of medium-
acuity patients may decrease the effect of ED crowding
on this group of patients and improve overall patient
flow.
In this investigation, our primary objective was to
study the effect of a dedicated “midtrack” area on key
CMS ED patient flow metrics, ED LOS, and overall left
without being seen (LWBS) rates. Secondarily, we esti-
mated the effect of this intervention on higher- and
lower-acuity patients. Our key hypothesis was that a
dedicated midtrack area will lead to a reduction in over-
all ED LOS and LWBS rates.
METHODS
Study Design
This was a retrospective 24-month pre- and postinter-
vention study of a dedicated midtrack area in the ED.
The institutional review board at the study hospital
approved the study protocol.
Study Setting and Population
The study period ran from January 1, 2010, to Decem-
ber 30, 2012. The study was performed at a tertiary care
adult urban ED with approximately 68,000 annual visits,
with a 4-year emergency medicine (EM) residency pro-
gram, a dedicated fast-track area staffed by midlevel
providers, and separate psychiatric emergency evalua-
tion center (PEEC), as well as trauma resuscitation bays.
The allocation of physician and nursing resources in the
ED during the entire study period was based on geo-
graphic assignment with nurses covering contiguous
rooms that align with the same physician care team and
goal patient-to-nurse ratio of four to one. The PEEC is a
separate area from the ED, with a dedicated waiting
area and treatment bays that are staffed by psychiatry
attendings and residents as well as a dedicated group of
nurses. Patients who arrive to the ED with primary psy-
chiatric complaints are transferred directly to the PEEC
after initial triage. The trauma bays, while contiguous
with the ED, are staffed by a trauma surgery team and
nurses that are separate from the ED. While the ED
senior resident and ED attending assist with trauma air-
ways, the trauma bay does not use any of the ED
resources. No other major interventions occurred dur-
ing the study period.
All patients who presented to the study center on
weekdays were eligible for inclusion. Because we were
435
studying the effect of an intervention on ED flow, the
following groups of patients were excluded from analy-
sis: patients triaged directly to the PEEC or trauma bay,
patients transferred from the ED to other institutions,
and patients who died or were dead on arrival in the
ED. We excluded these patients either because they
received their care in other areas separate from the ED
with their own dedicated resources or because their
LOS was dependent on the transfer mechanisms to
other institutions or to the morgue. We also excluded
patients who presented during a brief 4-day pilot of the
intervention prior to full implementation. Although
the hours of the midtrack intervention were from 1 p.m.
to 9 p.m., we included all patients because the benefits
of the intervention may carry over to all patients arriv-
ing later in the day, thus affecting overall patient flow.
Study Protocol
A dedicated midtrack area was fully implemented in
January 2012 after the pilot period in December 2011.
The area included three dedicated examination rooms
and three hallway spaces. The fast-track area previously
used this space, thus the implementation of the mid-
track area reduced the dedicated fast-track area with
no change in the overall number of treatment spaces in
the study center. An attending physician who was reas-
signed from the main ED staffed the midtrack area so
the total number of attending hours per day was also
unchanged. The midtrack area, however, was staffed
with two additional registered nurses (RNs) for an addi-
tional 16 hours or a 3.4% increase in total nursing clini-
cal hours per day. The hours of operation were
weekdays from 1 p.m. to 9 p.m., corresponding to
historic peak patient arrival rates and waiting room
census. The midtrack physician identified eligible
patients from the waiting room by reviewing the RN
triage note, prior records, and overall triage evaluation.
All nurses who perform triage at the study center have
a minimum level of ED experience and undergo formal
ESI training and triage orientation. There was no
change in the RN triage process postimplementation of
midtrack. Physicians were instructed to identify patients
who they deemed to be uncomplicated medium-acuity,
ESI level 3 patients with a high likelihood of discharge
home.
The study center uses a computerized ED information
system (EDIS) with integrated charting, order entry,
and patient tracking (EMTrac; University of Pennsylva-
nia, Philadelphia, PA). This system allows, via a Micro-
soft Access (Microsoft Corporation, Redmond, WA)
database query, collection of patient demographic infor-
mation, patient flow time stamps, disposition, and pre-
cise reconstruction of state of the ED at the time of each
individual patient arrival.
The primary operational outcomes measured were
daily LWBS rates and patient ED LOS. LOS was defined
as the time from intake (first entry in the EDIS system)
to the time of patient leaves the ED (removed from the
EDIS system).
Data Analysis
To determine differences in daily LWBS rates pre- and
postintervention, analysis of variance (ANOVA),
436 Soremekun et al. • EFFECT OF MIDTRACK ON PATIENT FLOW

adjusted for high triage acuity level (daily percentage of
patients with ESI levels 1 or 2), and daily total patient
volume was performed. We examined the effect of the
midtrack area on the percentage of days with high
LWBS rates (>5%) using Fisher’s exact test. This analy-
sis was stratified by normal and high volume days (>190
patients per day). The thresholds for high LWBS rate or
high volume day was determined by ED leadership
based on sensitivity analysis on historic data and our
goal LWBS rate of less than 2%. Data are presented as
percent change with 95% confidence intervals (CIs). To
assess differences in patient LOS pre-/postmidtrack,
ANOVA on the log-transformed LOS adjusting for total
patient hours (a proxy for ED crowding), ED volume,
and patient acuity level was performed. Because LOS
was not normally distributed, a log transformation was
performed prior to analysis. All statistical analyses were
performed using SAS statistical software (Version 9.3,
SAS Institute, Cary NC). The Tukey-Kramer method
was used to adjust for multiple comparisons within the
ANOVAs. A probability of p < 0.05 was considered sta-
tistically significant.
RESULTS
A total of 133,094 patients presented to the ED during
the 24-month study period. Those meeting exclusion cri-
teria were as follows: 1) 35,032 patients who presented
to the ED on a weekend, 2) 2,186 patients triaged
directly to PEEC, 3) 2,680 patients triaged directly to the
trauma bay, 4) 450 patients transferred to another medi-
cal facility, and 5) 72 patients who were dead on arrival
or expired in the ED. Additionally, 771 patients who
presented to the ED during the December pilot phase of
midtrack were also excluded. The final sample included
91,903 patients, seen on 261 days pre- and 256 days
postintervention.
After implementation of the midtrack, there was no
clinically meaningful change in proportion of patients
assigned high, medium, or low triage acuity, nor a
change in the proportion of admitted patients (Table 1).
However, as shown in Table 1, there was an increase in
the mean daily ED volume (and number of days ED vol-
ume exceeded 190 patients) postimplementation of the
midtrack area. The median daily number of patients
cared for in the midtrack area was 13 (IQR = 10 to 16;
see Table 2 for midtrack patient demographics and ED
disposition).
The overall ED unadjusted LWBS rate decreased
from 6.9% to 4.5% (p < 0.0001) after implementation of
the midtrack area. Adjusting for ED volume, crowding,
and acuity, the LWBS rates decreased from 7.3% to
4.0% (p < 0.0001; Figure 1). The decrease in LWBS rates
primarily affected medium-acuity patients, with the
rates decreasing from 9.5% to 5.3% (p < 0.0001) in this
subset of patients. The LWBS rates for high- and low-
acuity patients decreased from 1.7% to 1.3%
(p < 0.0001) and 4.37% to 4.30% (p < 0.0001), respec-
tively. In addition to a decrease in the overall LWBS
rates, the percentage of days with high LWBS rates (>
5%) on normal-volume and high-volume days decreased
significantly (Figure 2).
Finally, the mean ED LOS for medium-acuity (ESI 3)
patients decreased by 36 minutes (343 minutes vs.
307 minutes, p < 0.0001). There was no change in the
LOS for low-acuity patients despite the midtrack using
the fast-track rooms that were previously dedicated to
the care of these patients. The LOS of high-acuity (ESI 1
and 2) patients increased by 24 minutes (331 minutes vs.
355 minutes, p < 0.0001); however, there was no signifi-
cant change (14.69 minutes vs. 15.21 minutes, p = 0.07)
in the time to room for these patients (Figure 3).
Table 2
Demographics of Patients Seen in Midtrack Area
Characteristic Percentage
Age (yr), mean (SD) 32.1 (12.7)
% women 75
Race (%)
White 21.3
Black 70.9
Other 7.8
Disposition (%)
Admitted 3.5
Placed in observation 2.9
Treated & discharged 93.6
N = 3,489 patients.

Table 1
Daily ED Population Characteristics

Pre Midtrack Post Midtrack

Characteristic (n = 261 days) (n = 256 days) p-value
Triage acuity level—mean % of patients/day classified as:
High, ESI 1 and 2 23.4 (22.9–23.9) 24.1 (23.6–24.6) 0.052
Medium, ESI 3 44.7 (44.1–45.2) 45.3 (44.7–45.8) 0.14
Low, ESI 4 and 5 31.9 (31.5–32.4) 30.6 (30.2–31.1) < 0.0001
Daily % of patients admitted to observation or hospital 26.7 (26.3–27.1) 24.7 (24.3–25.1) < 0.0001
Mean daily patient hours 889 (872–906) 942 (923–962) < 0.0001
Mean daily ED volume 173 (171–175) 182 (180–185) < 0.0001
Number of days ED volume >190 (%) 33 (12.6%) 79 (30.9%) < 0.0001

Number in parentheses is 95% CI.

ESI = Emergency Severity Index.
ACADEMIC EMERGENCY MEDICINE • April 2014, Vol. 21, No. 4 • www.aemj.org 437

12
11 Mid-Track
implemented
10
9

Percent LWBS 8
7
6
5
4
3
2
1
0

2011 2012

Figure 1. Monthly LWBS rates adjusted for volume, acuity, and crowding. LWBS = left without being seen.

100 60

90 50
88%
40
80
Percent Days LWBS rate >5%

30
Change in LOS (minutes)

70 24
Post-Pre Mid-Track

20
60 61%
10
54%
50 0 0

40 -10

-20
30
-30
20 20% -36
-40
10 Normal Volume Days High Volume Days -50
(Daily Census <190 patients) (Daily Census ≥ 190 patients)
-60
Total Days 228 177 33 79 1-2 3 4-5

Control (Pre) Mid-Track (Post) ESI Classification

Figure 3. Postimplementation minus preimplementation

Figure 2. Percentage of days LWBS rates exceeded 5% during change in LOS (minutes) adjusted for volume and crowding.
pre- and postimplementation periods. LWBS = left without ESI = Emergency Severity Index; LOS = length of stay.
being seen.

DISCUSSION ED, the benefits of reducing service time variability by

cohorting patients with similar needs can outweigh the
Emergency department crowding negatively affects sev- reduction in flexibility, especially when the volume of
eral of the Institute of Medicine quality domains, and these patients is high.13 This finding explains the suc-
EDs with high levels of crowding face the challenge of cess of dedicated fast-track areas as well as our dedi-
reducing their wait times and LWBS rates. Similar to cated midtrack area in improving patient flow. At our
other EDs, our medium-acuity patients have the longest study center, having a high volume of younger ESI 3
observed wait times and are more likely to LWBS.11,12 patients who require fewer resources (shorter service
Counterintuitive to the goals of triage, dedicated fast- times) relative to older high-acuity patients was a key
track areas providing care for the lowest-acuity patients factor that allowed us to gain significant operational
result in shorter wait times for these patients when benefits in creating a cohort of these patients. In addi-
compared to medium-acuity patients. To improve over- tion, given the heterogeneity of ESI 3 patients, to ensure
all LWBS rates, targeted interventions are needed to large enough volumes to justify the reduction in flexibil-
reduce wait times and improve overall patient flow of ity, we assigned responsibility for identification of mid-
medium-acuity patients. track patients to the midtrack attending physician.
While dedicating an area of the ED to a care of cer- These physicians have different risk profiles and skill
tain type of patients may reduce overall flexibility of the sets and are ultimately responsible for determining the
438
medical complexity and resource requirements of their
patients. These operational improvements occurred in
spite of an increase in overall patient volume and
inpatient boarding in the postimplementation period.
In addition to the operational benefits of cohorting
patients with similar service times, our implementation
of a midtrack area using only three examination rooms
demonstrates a significant concept discussed often in
the ED operations literature. While an attending physi-
cian and two nurses covering three examination rooms
may seem overresourced, using fewer rooms ensures
that patients are kept “vertical” during their stays in the
ED and a high turnover of rooms. Using the examina-
tion rooms for initial evaluations and then transferring
patients to hallway stretchers or back to the waiting
room ensured rapid turnover of rooms. This practice is
usually not the case in the main section of our ED,
where as is common in many EDs, patients usually
occupy rooms for their entire stays. While the concept
of keeping patients “vertical” during their stays in the
ED has been described in the ED design literature, mid-
track and physician in triage with an internal waiting
area are two interventions that leverage this idea to
improve the utilization of ED beds and improve patient
flow.14 Recognizing that the availability of ED beds is a
key bottleneck, especially in EDs with high inpatient
boarding rates and limited space to expand, redesigning
EDs such that patients use ED bays only when clinically
appropriate will be critical to maximizing patient flow in
crowded EDs, as we demonstrate with our midtrack
intervention.
We were able to implement our midtrack area using
ED rooms as well as physician staffing reallocated from
the fast-track area and main ED, respectively. By
performing analysis to identify spare capacity within
our current system, we were able to operationalize this
intervention and reduce overall LWBS with minimal
incremental investments. While reallocation of
resources maximizes our financial return of the inter-
vention, we estimate that the financial return would still
have been positive if it required adding additional phy-
sician coverage. Reallocation of physician resources
from the main ED and siphoning off easy ESI 3 patients
to the midtrack area (and thus increasing complexity of
patients in the main ED) may have contributed to the
increase in the LOS of high acuity (ESI 1 and 2)
patients, because we did not see an increase in the time
to room of these patients. We did have to increase our
total nursing hours by 16 hours per day, representing a
3.4% increase. We believe our incremental resources to
be minimal compared to other operational interven-
tions, such as physician in triage as described by Rogg
et al.15 Their intervention involved redesign of the front
end to add four additional examination rooms and was
staffed by 16 hours of additional attending physician
coverage as well as significant increase in nurs-
ing hours. Interventions published by Holroyd et al.16
and Han et al.6 also involved an additional 8 to 9 hours
of attending coverage per day and do not report on
nursing hours.
Finally, in reporting our results, we presented data on
number of days when the LWBS rate was beyond a
certain threshold. The threshold for high LWBS rate or
Soremekun et al. • EFFECT OF MIDTRACK ON PATIENT FLOW
high-volume day was determined by ED management
based on sensitivity analysis on historic data, where
elimination of days when LWBS rates was greater than
5% would lead our overall LWBS rate to be less than
the national benchmark LWBS rate of 2%. While most
operational papers report aggregate numbers, most
operational managers recognize that there are days
when ED operations are working very well, and then
there are “out-of-control” days usually driven by high
census (facility specific) and boarding. Analyzing data
from this perspective allows for better understanding of
the frequency of “out-of-control” days and better target-
ing of operational interventions. For example, if the
data show the aggregate LWBS rate at a study center
to be 4%, but this rate is driven by Mondays where the
LWBS rate averages 10%, then interventions should be
designed for Mondays and not for the other days of the
week.
Although there are limitations in our particular study,
the fact that patient volume and acuity increased after
midtrack was implemented would be expected to bias
the study toward the null. However, we found a clinical
and statistical difference in both LWBS rates and LOS
for all patients, not just those seen in midtrack. There-
fore, although our study design is not perfect, we
believe that the positive results in the context of bias
towards the null and minimal increase in resources
suggests utility for this approach.
LIMITATIONS
The retrospective study design, lack of randomization,
and single intervention site with dedicated trauma bays
and a PEEC may affect the generalizability of our con-
clusions and our ability to fully exclude all potential con-
founding factors and secular trends over the 24-month
study period. Although a randomized controlled trial of
two different ED design strategies (midtrack vs. no mid-
track) might be scientifically more valid, these types of
studies are not likely to ever happen in the “real-world”
setting where we try to improve clinical operations.17
There was a 3.4% increase in the daily total nursing
clinical hours that was required to staff midtrack. While
this increase is minimal compared to other operational
interventions, our study design limits our ability to attri-
bute operational improvements to increase in resources
versus the midtrack intervention and redesign in the
care process. An additional limitation is our failure to
track any countermeasures that may be associated with
improving patient flow, such as 72-hour returns of dis-
charged patients or upgrades in care of admitted
patients. Finally, the selection of the patients cared for
in the midtrack area was not standardized and was at
the discretion of the attending physician.
CONCLUSIONS
Implementation of a midtrack area dedicated to the
evaluation of uncomplicated medium-acuity patients
was associated with reduction in overall left without
being seen rates and ED length of stay for medium-acu-
ity patients. While our study describes the operational
effect, further study is needed to evaluate the effect of
ACADEMIC EMERGENCY MEDICINE • April 2014, Vol. 21, No. 4 • www.aemj.org
this intervention on other quality measures, patient sat-
isfaction, and resident education.
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