Overcoming stagnant flow: A scoping review of vertical movement in the emergency department.

Objectives: Improving emergency department (ED) patient flow has plagued many hospitals worldwide. "Vertical" flow improves throughput by maximizing use of chairs and waiting areas instead of beds. This process, however, is inconsistently described in the literature. The objective of this study was to collate existing evidence of successful vertical care programs.

Method: A scoping review was conducted within several databases utilizing key search terms to capture relevant traditional and gray literature. All articles were uploaded into Covidence (n = 1000). After duplicates were removed, remaining abstracts were initially screened by two reviewers (n = 731). Records identified by at least one reviewer subsequently underwent a two-reviewer full-text screening for inclusion (n = 46). This process yielded 36 articles. Finally, each record underwent data extraction by two independent study members and any inconsistencies were resolved by a third study member. Extracted data included 21 predetermined variables. Descriptive statistics were used to summarize results.

Results: Of the 36 included articles, most were published from the United States (91.7%), after 2014 (55.6%), and as a peer-reviewed article or abstract/conference proceeding (86.1%). While every article discussed some aspect of vertical flow, most (77.8%) were observational studies. Only half of the studies reported details of staffing and/or physical resources. A variety of challenges and success strategies were described, with several themes identified. Positive outcomes were reported by most articles (86%), although measurement of outcomes varied with the two most common being length of stay (69.4%) and arrival-to-provider time (55.6%).

Conclusions: The findings of this scoping review provide the first summative report of existing literature on vertical flow processes within the ED setting. Despite different measurable outcomes and varied processes, most articles support the use of vertical flow to improve throughput.