EXECUTIVE SUMMARY

A new, multifaceted triage process is credited with helping the ED at Palomar Medical Center in Escondido, CA, slash turnaround times and the left-without-treatment (LWT) rate without requiring additional spending or resources. The approach integrates elements of the provider-in-triage and split-flow models while also using waterfall-style shifts for certain physician/nurse teams in the ED.

The model devotes one of two triage rooms to a physician/nurse team that see only Emergency Severity Index (ESI) level 3 patients, requiring more extensive evaluation. Called “threeage,” the approach is in response to the fact that the Palomar ED sees 28% more ESI level 3 patients than the typical ED.

The physician/nurse teams serve in threeage for three hours in waterfall-style shifts, after which they float back to the ED to finish caring for the patients they evaluated during their threeage shifts.

The other triage room, dedicated to a nurse and an advanced care provider, is for ESI level 4 and 5 patients. The higher-acuity ESI level 1 and 2 patients largely bypass triage and go straight to the back of the ED for care.

In less than one month of using the new approach, patient turnaround times have declined by 11% and the LWT rate has gone from 2.6% in the six months prior to implementation to 0.5%.


The ED at Palomar Medical Center (PMC) in Escondido, CA, has used the provider-in-triage (PIT) model for years, and it has worked well. But since the hospital moved to a new, state-of-the-art facility in 2012, volume has nearly doubled, creating new throughput challenges. The problem became even more intense when a neighboring hospital closed both its behavioral health and stabilization units earlier this year, creating considerable pressure on the ED to manage a new group of behavioral health patients, many of whom are under psychiatric holds.

Realizing the current PIT approach was no longer keeping up with the volume demands, physicians and nurses in the ED collaborated on a new approach that combines elements of both the PIT and split-flow models as well as a waterfall approach to shifts. The early results have been dramatic.

Less than one month into the new approach, patient turnaround time in the ED is down substantially and the left-without-treatment (LWT) rate, a trouble sign for the department, has declined to near zero. All this has been accomplished without any additional spending or resources.

While the approach comes with inherent challenges and a level of complexity that takes some time to absorb, ED leaders are pleased with their progress thus far. They believe their journey through this implementation may offer lessons to other EDs facing similar throughput-related challenges.

The first year in the new hospital, the ED saw 68,000 patients, but that number has continued to climb, reaching 115,000 patients in 2018. “We’ve got the same thing that a lot of EDs have where we have a lot of inpatient [and] psychiatric holds. Throughput tends to be a challenge for us here,” says Desiree Hadden, RN, MSN, the nurse manager in the ED. “We really tried to go to the table with our physician partners and come up with a new process that could get people [through the ED] faster.” Some clues on how to proceed emerged from an analysis of the ED’s data, which revealed that the patient population the department serves differs in some respects from the typical ED, according to statistics from the National Hospital Ambulatory Medical Care Survey.

“We were looking at patient distribution based on our Emergency Severity Index [ESI] [triage scores],” observes Bruce Friedberg, MD, FAAEM, an emergency physician (EP) and the assistant medical director in the ED at PMC. “On average, we are seeing 28% more ESI level 3s than most hospitals. Those are the patients that generally require much more extensive evaluation in the ED.”

Further, the PMC ED sees significantly fewer lower-acuity patients than the average ED. Specifically, the ED at PMC sees about 30% fewer ESI level 4 patients and 67% fewer ESI level 5 patients, Friedberg shares. “These patients require a very limited amount of diagnostic and therapeutic evaluation and also get a much quicker disposition,” he adds.

This information prompted the medical team to consider a change to the current triage approach. Previously, the team had been directing an advanced practice provider to conduct a quick medical evaluation of patients up front and then start on workups. “We found that this rapid evaluation is much more difficult to do consistently and correctly on these usually sicker patients, the ESI level 3s,” Friedberg observes.

Consequently, the EPs and nurses worked together with the ED’s quality improvement team and the hospital’s staffing partner, Emeryville, CA-based Vituity, to redesign the triage process. Under the new approach, which the ED began using in mid-July, a patient who presents to the ED is assigned an ESI score by a nurse in the waiting room. The ESI designation is based on the patient’s chief complaint and a quick evaluation. This is where a split-flow triage process begins.

“One triage room is dedicated to a triage nurse and an advanced care provider. The [lower acuity] ESI level 4s and 5s will go there,” Friedberg explains. “The second triage room is dedicated to the ESI level 3s. We call that the ‘threeage’ room, and it is staffed by a nurse and a physician.”

By staffing the threeage room with a physician and a nurse, the thinking is that these clinicians will be better equipped to assess the needs of these more complicated patients. Further, these staffers could complete appropriate tests and/or workups in progress more quickly than the advanced practice providers could previously.

“They are seeing all the ESI level 3s who are coming in with the expectation that the physician-nurse team is going to see each patient and stick with each patient throughout his or her stay in the ED,” Friedberg shares. “Physicians perform a much more expanded history and physical [on the ESI level 3 patients] in addition to and in conjunction with the triage nurse. Then, they initiate appropriate comprehensive workups with the goal of keeping those patients to completion. This way the providers are making an early connection with the patients, and they can let them know that they are going to be their provider during the entire ED stay, which is one of the most important parts of this [process].”

As part of the patient evaluation in threeage, the physician/nurse team also will determine whether the workups required can be completed while the patient is sitting in the waiting room. If so, these patients are designated “vertical 3” patients on the ED tracking board. Alternatively, the ESI level 3 patients who require a bed while workups are completed will be placed in one as soon as a bed becomes available. These patients are designated as “horizontal 3” patients on the tracking board.

“We have set up guidelines of what makes an appropriate horizontal ESI 3 patient vs. a vertical ESI level 3 patient, and we have educated staff about this,” Friedberg notes.

The most acute patients who present to the ED, the ESI level 1 and 2 patients, largely bypass both triage rooms. Instead, they are taken into the ED immediately for care. Further, there are times when an initial ESI designation is incorrect. When that occurs, the ESI designation is changed, typically during a patient’s evaluation in one of the triage rooms, Friedberg notes.

To be sure, seeing nothing but ESI level 3 patients in the ED is intense work. Thus, the physician/nurse team fulfilling this role only does so for a three-hour shift. Then, the next physician/nurse team takes over in threeage while the first team retrieves any results or workups that were ordered for the patients who they began seeing while in threeage. The original team continues caring for these patients until their disposition, providing consistency for the patients.

“We call these waterfall shifts. They start off there [in threeage], and then flow into the back as a waterfall,” Friedberg explains. “There are five different [physician/nurse] teams throughout the day [from 8 a.m. until midnight].” Friedberg acknowledges that staff physicians were not universally enthusiastic about the new approach when it was first introduced.

“There definitely were concerns. Those three hours [in threeage] are rough. I have seen 20 patients in those three hours,” he shares. However, physicians have come to appreciate some of the benefits of the new approach. For instance, on average, most physicians who complete these shifts can slowly taper off seeing patients as they reach the end of their threeage shifts and complete their charts, Friedberg notes. “They are getting out on time or close to on time, which is an unheard-of thing for us,” he says.

Nonetheless, Friedberg acknowledges that the three-hour shifts in threeage probably still are too long. Most labs and other workups that are ordered for the ESI level 3 patient usually are back and ready to be reviewed and acted on before the physician/nurse teams are relieved from their threeage shifts. He envisions further tweaking of the approach.

“Just looking at the average time it takes for initial labs and radiographic studies to come back — I think two hours is probably a sweeter spot,” shares Friedberg, referring to what the ideal length for a threeage shift might be. “In the next couple of months, we may be looking at changing the process a little bit so that the waterfall shifts are actually two hours and there are more of them. Once you leave the triage room, and you head back to the main ED, that is when the results are starting to flow back.”

While some tweaking of the approach is likely, ED leadership could not be more pleased with the early results. In fact, in just three weeks, the new process exceeded the collaborative’s initial goals, which were to reduce patient turnaround time by 10% and to curb the ED’s LWT rate.

“In less than one month we have seen our turnaround times to discharge drop ... from 248 minutes down to 220 minutes compared to [data from] the prior six months,” Friedberg reports. “What I find even more impressive is since the patient is making that initial connection with the provider and they know that this provider is going to be following them, our LWT percentage has gone from 2.6% on average in the six months prior [to implementation of the new process] to 0.5%.”

Hadden notes that initially, the ED completed several different trial days of the new model to see how it would work under challenging circumstances. “Mondays are always very high-volume for us, so we trialed it on a Monday. We did it on a day when one of our CTs ended up being down,” she says. “There were different results on all of these days, but all of them showed a decrease in the turnaround time to discharge and in the LWT rate.”

Administrators were particularly focused on reducing the LWT rate because they view this as a safety and quality issue as well as a financial one, Hadden notes. “Every time a patient walks out the door [before being treated], that is money that is walking out the door as well,” she says.

While the changes to the triage process are largely credited with the improvement in patient turnaround times, Hadden notes other operational tweaks have played a role, too. For instance, she says there are now two designated transporters for patients requiring diagnostic imaging to eliminate any time between radiographic procedures.

“Somebody is always getting a test, and somebody is always right outside waiting. We are just constantly keeping that going,” she says. There also have been changes to the registration process so that it is no longer something that is completed at the end of an ED visit. Rather, the process occurs now while the patient is in the waiting room or during another downtime in the course of the visit.

“We’ve got a team of volunteers who will either bring the patient to the registration area to get registered, or the registration person will go to the patient,” Hadden shares.

For other EDs that are intrigued by the multifaceted approach to triage that PMC has implemented, Friedberg stresses that effective communication with patients is one of the most important factors to making the model effective. In particular, after patients leave triage, patients need to understand that tests are completed while they wait to hear from their providers and that things are happening. “We have seen that patients really do appreciate the communication and getting through the ED more quickly,” Friedberg says.

Another critical factor is making sure physicians, nurses, and ancillary staff are all well-informed about how the new model works.

“We have actually been contacting each advanced care provider and physician before their shift to discuss the process, answer any questions, and make sure everyone is on the same page,” Friedberg says. “This has been a pretty radical change for us.” Before embarking on any change process, Friedberg advises colleagues to become well acquainted with their current data.

“You have to know where you stand; the numbers don’t lie,” he says. “I think it is important to look at your ESI [acuity level] distribution. We have actually broken our turnaround time to discharge down into [sections] based on ESI [level] so we can really tell where our pinch points are located.”

For EDs with a higher percentage of ESI level 3 patients, the threeage process may offer similar benefits, Friedberg notes. Hadden adds that the model requires an actively engaged provider group and good relationships with ancillary departments. “We meet monthly with our radiology and transport teams,” she says. “We’ve got these embedded relationships so that when we go to them and say we’ve got this initiative we want to do, they are more likely to jump in and be collaborative with it.”

The triage process still is relatively new to the ED at PMC, and there may be some fine-tuning in the months ahead. However, administrators intend to keep the new approach for the long term.

“What we see right now is that it is working and it is working well. Now, we just need to focus on sustainability,” Hadden says. “This isn’t just going to be a flavor of the month. This is something that is here to say with our ED.”