Critical Path Network: ED triage improves patient flow
Critical Path Network
ED triage improves patient flow
Rapid care area moves patients through system
A new emergency department (ED) triage system at Baptist Hospital in Pensacola, FL, decreased the time that elapses between when patients arrive and when they are treated by 33%, slashed the number of patients who left without treatment by 50%, and cut 20 minutes off the total turnaround time from when patients arrive at the ED and when they are discharged or admitted.
While the ED census remained stable, the total turnaround time dropped from an average of three hours and 35 minutes in the year before the program started to an average of three hours and 15 minutes in the first year of the program.
"In the world of emergency departments, that's a significant time improvement. We treat about 60,000 patients a year, so that's a tremendous amount of nursing time saved," reports Michael Dolister, MD, assistant chief of staff and ED physician.
CM deals with admissions
The hospital has a case manager on site in the ED whose duties include assuring that patients meet admission criteria, are admitted in the appropriate status, and that preadmission certification and other details required by the insurance company are completed.
When patients don't meet admission criteria, the case manager helps find an alternative setting of care, such as a nursing home, or lines up home health services.
"The case manager is involved in all the admissions, as well as helping to expedite patient flow in the emergency department," says Cindy Heidorn, director of emergency trauma.
Before the hospital revamped the ED in 2007, a multidisciplinary team analyzed the hospital's patient flow, looked at all the obstacles that the staff encounter in moving patients quickly through the continuum, and evaluated the most effective way to safely move patients through the ED.
The team created workgroups to generate ideas from the staff and ED physicians, and then educated the entire staff about the new processes, reports Paul Ropp, BSN, CEN, RN, who led the educational effort.
In the past, when patients came in early in the day and rooms were available, the patients were not placed in the room immediately, which began to cause backlogs by late morning.
"Because we have limited capacity, we would reach a saturation point and patients would be left sitting in the waiting room," Dolister says.
The new system triage-bypass allows the ED staff to attend to patients more quickly and admit or discharge them before volumes begin to peak, he says.
"Bypassing triage allows patients to be immediately directed to an available room where the triage and nursing assessment can begin. Otherwise, less acute patients are required to remain in a queue in the waiting area of the emergency department until an RN can perform this function," he adds.
The hospital's ED uses the emergency severity, index, which stratifies patients according to their levels of severity.
Level 1 patients have emergent needs, such as cardiac arrest or uncontrolled bleeding, and must be seen immediately. Those on Level 2 have urgent needs, including signs of a stroke or heart attack, and should be seen quickly. Level 3 patients are acute with problems such as abdominal pain, vascular bleeding, or major vomiting.
Patients on Level 4 have chronic conditions or minor orthopedic injuries and may need X-rays. Level 5 patients are stable and typically don't require lab or X-ray services.
"In the past, Level 1 and 2 patients were brought back to the treatment rooms rapidly. Patients on Level 4 and 5 with lower acuity were taken to the fast-track area and were treated fairly quickly. Level 3 patients often waited the longest because they would get bumped when patients on Level 1 and 2 came in," says Sally Campbell, RN, MH, CRNI, ED triage nurse.
Benchmark other hospitals
When they studied what other hospitals had tried, the team determined that many hospitals had tried adding a midlevel provider to their triage staff, but had determined that it wasn't an effective solution for them.
"We chose to add an experienced nurse to the triage area during peak hours to get the necessary tests and evaluations on the medical staff-approved clinical pathways started before the physician sees the patient," Dolister reports.
Patients who are on Levels 1 and 2 of the severity level still are immediately brought back to the treatment rooms. Patients with the least severity, on Levels 4 and 5, are triaged to the fast-track area.
Level 3 patients, those who need a work-up but do not have emergent needs, now go to the rapid treatment area, a separate room with six chairs, where Campbell completes the nursing assessment and orders work-ups and procedures, such as X-rays and urine tests, using physician-driven clinical pathways.
In the past, those patients would have been triaged to the waiting room until a treatment room was available.
"Now the blood is drawn and the initial orders have been processed before the physician sees the patient. This is very effective in getting the treatment started," Dolister says.
The hospital has used clinical pathways in the ED for 11 years.
"The nurse can drive those even when a patient is already in a room by using physician-driven order sets," Dolister says.
The hospital has a process in place that allows the ED physicians to write bridge orders for patients who have been evaluated and stabilized by the ED staff.
"It often takes a while for the admitting physicians or the hospitalist service to return a page and issue the orders. While we are waiting, the bridge orders allow us to get the treatment started," Dolister says.
At Baptist, members of the ED leadership team make follow-up calls to patients after an ED visit to get their input on their hospital experience, particularly how the discharge instructions were delivered.
The ED director, the clinical manager, the educator, the trauma coordinator, and the ED analyst coordinator all make five calls every day, which represents approximately 15% of the daily ED volume.
Each one is assigned an increment of time in a 24-hour day and they make random calls to patients who were seen in the ED during that time frame.
"It gives us a wonderful window into what happens when people come into the emergency department. If their perception was that the department was unresponsive to their needs or they were kept waiting a long time, we can immediately look at the situation and determine how to correct it," Heidorn says.
The telephone calls have enabled the administration to make changes to improve patient satisfaction, she adds.
For instance, the team found that many patients with nonemergent issues wanted an explanation of how long they were going to have to wait and why.
"If patients are going to have a test, and it takes 30 minutes for the results to be ready, we find our patients are most satisfied if we let them know. This helps them understand why they are waiting and also manages their expectations," Heidorn adds.
(For more information, contact Cindy Heidorn, Director of Emergency Trauma, Baptist Hospital, Pensacola, FL; e-mail: [email protected].)A new emergency department (ED) triage system at Baptist Hospital in Pensacola, FL, decreased the time that elapses between when patients arrive and when they are treated by 33%, slashed the number of patients who left without treatment by 50%, and cut 20 minutes off the total turnaround time from when patients arrive at the ED and when they are discharged or admitted.
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