'PIT' more than triples ED's satisfaction rates

Averages for LOS and LWBS more than cut in half

How would you like to boost your patient satisfaction scores from the 30th percentile to the 96th percentile with a single new strategy in your ED? If that's not enough, how about a 44% reduction in your LWOT (left without treatment) rate and a 42-minute decrease in your average length of stay (LOS) for all patients?

Those impressive performances were turned in by the ED at Parma (OH) Community General Hospital between Jan. 1, 2007, and March 10, 2007, as the result of a pilot test for its new Physician in Triage (PIT) program.

The traditional LWOT rate in the ED had been 4.8% prior to the PIT program. Following implementation, it dropped to 2.7%. The average LOS before the program was 293 minutes. Following implementation, it was 251 minutes.

"We started toying with the idea [of a physician in triage] in the fall of 2006," recalls Jesse DiRando, MD, FACEP, director of emergency services. In fact, he adds, it had been tried earlier, but it didn't work well without much cooperation from the hospital. "We had a substantial administration change and new nurse management, who liked the idea and was committed to it as well," he explains.

They spent about two months putting the project together; obtained buy-in from administration, nurses, and physicians; and implemented the plan on a half-time basis to see if they were actually getting improvements. "Out premise was the following: Could we improve satisfaction, accuracy of triage, proper diagnosis, and proper lab and radiology studies at the front end by having a physician there — the highest-trained person in care of the patient seeing them first?" DiRando explains.

A parallel process

The traditional triage process is a serial process, DiRando says. The patient presents, then evaluation begins by nursing or clerical staff. Next, they are sent to the ED or fast-track facility or waiting room, with no orders. The physician then evaluates the patient, arrives at a diagnosis and orders treatment; the orders are executed, studies returned, the patient is re-evaluated by the physician, and final disposition is determined.

"In the PIT model, we created a team that handles evaluation and treatment while we simultaneously register the patient," says DiRando. The team includes one triage physician, two RNs or LPNs — one medic can be substituted for a nurse, but never two — one ED tech, and one float tech. In this "parallel processing," the patient walks in the door, comes to the triage window, and is greeted by the registrar, who takes only the name and a minimum amount of information to "quick-reg" them in order to obtain a medical record number. Then they go into the triage room, where the doctor and nurse conduct triage simultaneously. "If we know labs will be required, the tech immediately draws blood right then," adds DiRando. The doctor enters orders for lab or radiology studies and determines where the patient will go next. Low-acuity patients go to fast-track, where they are seen by a physician assistant (PA) who collaborates with the triage doctor. Higher-acuity cases are sent to the main ED, where they are seen by ED physicians.

Cost-free pilot

The three-month pilot program was a cost-free method of demonstrating the success of this approach to staff and administration. "We started out with half-days of traditional staff and the other half PIT, to allow a basis of comparison," says DiRando, adding the schedules were rotated on different days to ensure an accurate comparison.

As with most new processes, everyone was skeptical at first, says Carl Schikowski, MD, an ED "physician champion" for the new program. "However, after a couple of weeks of seeing how it works, they were all pretty much on board," he says.

The improvement in patient satisfaction is the one that "sold everybody," says DiRando. The patient satisfaction scores were provided by Press Ganey of South Bend, IN. "In addition, we have been able to discharge 8% of the patients seen by PIT, and they never entered the ED," DiRando says.

DiRando says the staff have evolved "from resistance to acceptance, and now to commitment and reliance on the new process." By the end of the pilot period, on the days they were not using PIT, "they got upset and angry they weren't doing it," he says.

Now, the ED is going to PIT full-time, and some additional costs will be incurred. The additional cost was the hiring of a PA to fill a shift, DiRando says. "But recaptured revenue from the decreased LWOT rate more than paid for the additional required staff," he says.

The program has exceeded expectations, says Schikowski. "It's an unbelievable relief knowing that every appropriate test had been ordered, and in a lot of instances, they're done by the time you pick up the chart," he says. "It's a huge timesaver."


For more information on physicians in triage, contact:

  • Jesse DiRando, MD, FACEP, Director, Emergency Services, Parma (OH) Community General Hospital/ Emergency Medicine Physicians of Cuyahoga. Phone: (440) 743-4020. E-mail: JDiRando@emp.com.
  • Carl Schikowski, MD, Parma (OH) Community General Hospital. Phone: (440) 743-4020.