Streamlined process cuts time to triage in half

Leadership retains only the most essential steps

The time-to-triage in the two very busy EDs in the Children's Healthcare of Atlanta system has been cut in half in less than a year through a process improvement initiative that eliminated several steps in the initial assessment.

In a statistical review during winter 2006, "We were seeing a 28- to 47-minute mean wait time to triage during busy hours just to see an RN, and we knew that was entirely too long," reports Marianne Hatfield, RN, BSN, system director of emergency services for Children's Healthcare of Atlanta. The ED at the Egleston campus sees about 40,000 patients per year, and the ED at the Scottish Rite campus sees 80,000 patients per year.

"We thought we had done all we could do, like eliminating triage when we had rooms available, but once we had gridlock, the wait became entirely too long," she says.

This wait time led to an ED planning meeting in April 2007, adds Kim Crawford, RN, an assistant nurse manager in the ED on the Egleston campus. "We had looked at other facilities facing similar issues and had documented their experiences," Crawford says. "We basically decided we needed to look at our process and see what was absolutely necessary when the patient walked in the door vs. what could be done at a later time."

Also, Hatfield says, they already had converted to the Emergency Severity Index (ESI) tool for triage that stratifies patients on a scale of 1 to 5, with 5 being the least urgent. "But it had not given us the reduction we were looking for, so, we went to the basics of the military approach to determine who is sick and who is not, and if they are sick, just how sick they are," she says.

Eliminating steps

The bicampus ED leadership team, which includes assistant managers, administrative resource nurses, educators, trauma coordinators, managers, and Hatfield, had participated in the earlier meetings. The team met again in April 2007 and brought in frontline staff and physicians.

"They were almost doing a full general assessment before, and they cut it down to the most essential steps," says Hatfield. Those steps were:

  • identification;
  • presenting symptoms;
  • pertinent medical history;
  • diseases exposure (i.e., travel outside the United States in the past month);
  • allergies;
  • a very brief ABCD (Airway, Breathing, Circulation, and Disability) visual assessment.

"We streamlined the process down to the things we needed to have to correctly sort that patient to the appropriate acuity level without causing harm to the patient, ourselves, and the department," Crawford explains. "We eliminated vital signs and other parts of the process such as a full neurological assessment, using the stethoscope, or initiating procedures like pain control or fever meds."

Process piloted first

At the end of May, the new process was introduced to a selected group of staff in a pilot program. Certain high-volume days and times were selected. "Scottish Rite is very predictable, and we chose 3 p.m. to 3 a.m.," says Crawford. "We did 11 a.m. to 3 a.m. at Eggleston." These shifts, she notes, involved between six and 10 nurses and technicians.

At Egleston, Crawford held a special meeting on the process, sharing step-by-step diagrams she had made. "I also showed them on a [computerized graphic] presentation how backlogged we were," she adds.

The entire program went live on June 16. "At first, the staff did not like it, but then, when do they ever like a new process?" says Hatfield. "However, it made such a tremendous difference, it helped them buy in quickly." Time to triage by registered nurse decreased from 27 minutes to eight minutes, she says.

In addition to slashing wait times, the percentage of patients who left without being seen (LWBS) also was reduced dramatically, says Hatfield. "It went from 1.7% to 0.7% at Egleston, and from 0.9% to 0.3% at Scottish Rite," she reports. Since patient satisfaction has always been well over 90%, it was not really affected by the new process, Hatfield says.

Another factor that contributed to the success of the new process was the tightening of requirements for triage nurses, she says. "We created a more stringent policy, because you want them be a little more experienced, and make sure they really have their triage skills down," Hatfield explains. Nurses with no pediatric ED experience must have one year of ED experience, says Crawford, and if they do have pediatric ED experience, "we require a bare minimum of six months."

This process improvement initiative would work in any ED, pediatric or adult, Hatfield says. Crawford says, "The other interesting thing is that our system really tapers staff [according to demand], as many EDs do, but even with minimal staff, like three nurses at 7 a.m., we are still able to do this process."

They also decided to look at whether they had more "missed" triages with the new process, says Hatfield, "and we actually saw improvement in our triage acuity assignment."


For more information on reducing time to triage, contact:

  • Marianne Hatfield, RN, BSN, System Director of Emergency Services, Children's Healthcare of Atlanta, Atlanta. Phone: (404) 785-4968. E-mail: