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Ambulatory Care Quarterly
ED sees 50% reduction in time from triage to ED bed
Define problems and then benchmark
(Editor’s note: In this first part of a two-part series on benchmarking, we tell about two hospitals that achieved dramatic reductions in length of stay (LOS). Next month, we discuss how to speed up admissions by addressing virtual capacity issues with the entire hospital.)
Would you like to see a 50% reduction in time from triage to emergency department (ED) bed? How about significant improvement in LOS for admitted patients and treated and released patients? These are some of the concrete benefits that the EDs at Lehigh Valley Hospital in Allentown, PA, and Saint Rita’s Medical Center in Lima, OH, have achieved with the targeted application of data uncovered through benchmarking.
"What we have done here is benchmark to define problems," says Richard MacKenzie, MD, FACEP, vice chairman of the department of emergency medicine at Lehigh Valley. Keeping the problem in the forefront has been one major lesson of his benchmarking experiences, he says. "Also, you have to be able to monitor the effect [you have had] on the problem," he adds.
Saint Rita’s modeled the success of a similar facility by copying a single practice it learned of through a news story and reduced overall LOS from 190 minutes to 160.
The key issues at Lehigh Valley were identified by a collaborative management team of nurses and physicians that had been leading a series of subproject teams to focus on prolonged ED LOS.
"The subprojects we identified were bedside registration and rapid triage," MacKenzie notes.
Using national data provided by Karpiel Consulting Group in Long Beach, CA; the Institute for Healthcare Improvement in Boston; and Press Ganey Associates in South Bend, IN, the team found they took probably 10-20 minutes longer than most of their benchmark facilities to place patients into an ED bed.
"We were still doing front registration and had a very sequential process of triage, then registration, then to the ED," MacKenzie explains.
Now, the process is parallel, he says. "We do a short triage, get a bed available, the patient goes back to bed, and we do a short registration there," MacKenzie adds.
If there aren’t beds available, patients receive a short triage. Subsequently, they go back to the waiting room. When a triage nurse is free, they return to triage for complete assessment and possible labs, and then return to the waiting room until a bed becomes available. The short triage is done in the presence of a registration clerk, who takes the patient’s name, Social Security number, and perhaps, date of birth. The triage, which takes about five minutes, includes the Emergency Severity Index (ESI) and vital signs, if there’s a high-risk complaint.
"We’ve seen about a 50% reduction in time from triage to ED bed: from 37.8 minutes monthly average to 16.8 minutes monthly average," MacKenzie reports.
As part of Catholic Health Partners, Saint Rita’s benchmarks against corporate data, as well as using Press Ganey and the Emergency Department Benchmarking Alliance, a nationwide group of emergency physicians and nurses. Lehigh Valley also participates in this alliance.
However, one of its most memorable initiatives came as the result of a news report about a 30-minute ED pledge made by Oakwood Hospital and Medical Center in Dearborn, MI, recalls William E. Tucker, MD, FACEP, Saint Rita’s medical director of emergency services.
"They promised their patients they’d be seen within 30 minutes or they would be given a present," he says. "We benchmarked how they did that."
During the same time period, the staff at Saint Rita’s had conducted customer surveys and found that aside from receiving good care, what patients cared about most was how much time they spent in the ED. These survey results reinforced the need for the project.
"What we copied was moving our treatment rooms closer to the front door, keeping our waiting room empty, and getting patients back to the room as quickly as possible," Tucker notes. The Oakwood model was adapted to meet the specific needs of Saint Rita’s. "For example, we did not have the ability to have a physician at the front door, like Oakwood did, so we put a PA [physician assistant] there," he says.
In the past, patients were seen by a nurse in triage then assigned to express care, pediatrics care, or acute care. Next, they were put in a room and seen by a doctor before anything was done. Now, the PA is certified by hospital bylaws as a medical screening examiner with the power to order diagnostics.
"We put in wireless phones, which allowed the PA to have private conversations with docs about patients," Tucker explains. "The physicians are able to give verbal orders to start therapeutics."
The initiative has been extremely successful and led to a significant decrease in left without being seen patients. "We have 0.75% of patients leaving without treatment, which is much lower than any national average," which is usually 2% to 3%, Tucker says.
It also has resulted in a decrease in LOS: for treated and released patients, from 169 minutes to 143 minutes; for admitted patients, from 341 minutes to 284 minutes; and for overall LOS, from 190 minutes to 150 minutes, he adds.
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