The hospital credits sustained improvement on this metric — among several other markers of emergency department efficiency — to a “vertical bay” program that enables ED leaders to manage patient flow more effectively.
The hospital implemented the program in 2022 in response to rising emergency department volumes, both from EMS transports and front-door arrivals. The program allows the ED to accommodate the rise in patient volumes without needing to expand its physical footprint.
The vertical integrated process entails using small bays to treat patients who can sit safely while receiving care, such as those awaiting test results or minor treatments. The initiative also incorporates a structured movement system, whereby patients transition between designated spaces — including ED bays, hallway beds or chairs, and the waiting room — based on their needs.
While the program had already driven significant improvements by late 2023 — bringing the LWBS rate down from 11% to 3.7% — progress began to level off. By January 2024, when current ED Director Stephen DeVito, MSN, joined the hospital, this rate had plateaued around 1.4% — just shy of its goal of less than 1%. Seeing an opportunity for further refinement, Mr. DeVito took a hands-on, collaborative approach with front-line staff to refine the program and drive even greater efficiency.
At first, he encountered some skepticism. “Who is this new guy, and why is he asking all these questions?” was a common sentiment. But by shifting the focus to patient stories — emphasizing that 3.7% of patients were still not getting the timely care they expected — he helped the team see the need for further improvement. Staff members became more involved in testing and refining ideas, embracing a culture of continuous problem-solving.
“When we started to connect the patient’s story, I think that’s where the success was,” he told Becker’s. “Lights went on, and they started to get more engaged. We tried some things that worked, we tried some things that didn’t, and they loved being a part of [that process].”
The team implemented three major refinements that helped accelerate progress:
1. Creating a flow coordinator role. One of the biggest opportunities for improvement was establishing clear ownership of patient movement through the ED. Historically, charge nurses managed ambulance arrivals and critical patients in the back of the ED, while triage nurses handled front-door arrivals. Due to the ED’s large, expansive layout, charge nurses had limited visibility into front-end operations, creating a gap in oversight for patients who had been triaged but were still waiting to be placed.
To address this, the hospital introduced a “flow coordinator” role, assigning a registered nurse to manage this interim period and ensure patients were efficiently directed to the appropriate care space.
“Having somebody own that space, as a flow coordinator, really helped [drive] that next evolution for us,” Mr. DeVito said.
This role formalized a “triangle of flow,” improving communication and coordination between the charge nurse, triage nurse and flow coordinator to better manage patient throughput in the ED.
Just last month, the hospital introduced a dedicated flow-tech role to support the flow coordinator, who had become overwhelmed with quick tasks like blood work and flu swabs during the busy virus season. By taking on these responsibilities, the flow tech allows the flow coordinator to focus on managing operations and patient movement. While in its early stages, Mr. DeVito noted that the hospital is already seeing a reduction in length of stay with this added support.
2. Adopting a movement-based process. Initially, the vertical bay program operated as a static process, where lower-acuity patients remained in one of its three vertical bays during the duration of their visit. As ED volumes surged, this led to bottlenecks. To improve efficiency, the team evolved the program into a movement-based system. Now, after being triaged and evaluated in a vertical bay, patients are often moved elsewhere, depending on their condition and current ED capacity. For example, a patient awaiting a flu swab result may be moved from the bay to a hallway bed or chair until they receive their results.
This shift from a fixed system to a movement-based model marked a turning point in accelerating improvements, according to Mr. DeVito. By July 2024, the hospital had achieved a sustained reduction in its LWBS rate. Its average door-to-provider time also started to fall. At the start of 2024, this figure averaged about 32 minutes. At present, this figure hovers around 21 minutes.
“Not at goal, but moving the needle,” Dr. DeVito said. “You can almost put a pin in it from when we started the optimized vertical integration process and really got the teams buy in for it,” he said.
After the new process was implemented, patient feedback revealed confusion about why they weren’t staying in one place, which affected HCAHPS scores. In response, the team introduced “patient passports” — guides given at reception to clearly outline the ED process, including triage and movement expectations. This patient education tool contributed to the hospital finishing in the top quartile for HCAHPS in the fourth quarter of 2024.
“So we’re super proud that we’re hoping that we can kind of sustain that movement that we’ve seen with that implementation of not only how we use our space, but how we’re communicating we’re using our space,” Mr. DeVito said.
3. Enhancing physician participation and structured rounding. A third major refinement was the implementation of formal board rounds with ED physicians every two hours. These structured touchpoints — separate from the existing “triangle of flow” conversations — provided a dedicated opportunity for real-time problem-solving and prioritization. During these rounds, physicians and ED leadership assess patient movement and identify barriers slowing care progression. Integrating physicians more directly into flow discussions has improved coordination between providers and support staff, ensuring that test results, orders, and other dependencies do not cause unnecessary delays.
Looking ahead
Since launching at AdventHealth Carrollwood in 2022, the vertical bay program has expanded to three other hospitals within the system, demonstrating its effectiveness in optimizing patient flow.
“Innovating space to your unique emergency department layout is really important. If you stay proactive in how you’re using the space, engaging the team, it allows you to stay ahead of fluctuations based on surge patterns in the ED,” Mr. DeVito said.
Through a combination of clearer patient-flow management, a dynamic movement-based process and stronger physician engagement, AdventHealth Carrollwood has significantly improved ED efficiency, reducing LWBS rates and door-to-provider times, and boosting patient satisfaction scores. As the program continues to expand and evolve, hospital leaders remain focused on sustaining these gains and further optimizing emergency care to meet growing patient demand.
