Accelerated triage cuts LWBS rate in half

Integrating new IT system key to speed process

An accelerated triage process developed by the ED staff at University of California San Diego (UCSD) Medical Center has reduced the frequency of patients who left without being seen by a physician by almost 50% from about 8% to 4%.

They attribute this reduction to the program’s ability to decrease patient wait times for care from 50-60 minutes to 24 minutes, and patients’ average length of stay in the ED from seven to eight hours to about 5.5 hours.

The program, called ED REACT (Rapid Entry and Accelerated Care at Triage), streamlines the registration process, improves triage efficiency, and begins tests and interventions on patients before they are placed in ED beds.

"Basically, when patients come into the ED and there are no beds, rather than leave them in the waiting room unattended, a triage nurse can accelerate care by calling a doc, who may order things like X-rays or draw lab work," explains Karen Jones, RN, MS, director of emergency nursing for UCSD Medical Center.

To facilitate that happening, the ED instituted a quick registration process and obtains just enough information — name, date, and chief complaint — so the patient could be registered and receive an armband. This process allows the ED to facilitate tests in the waiting room.

"So, by the time the patient got into a bed, hopefully the results were coming back, and ultimately that decreased the amount of total time [that person] stayed in the ED," Jones says.

Before this process, about 15% to 20% of patients went from triage to an ED bed, all based on acuity, notes Ted Chan, MD, professor of clinical medicine and medical director of the ED.

"Otherwise, they were pushed to the waiting room to be registered," Chan says. Now, since they’ve removed the need for an upfront lengthy registration, any open bed gets filled, he explains. "Fifty percent of our patients get into a bed from triage," Chan says.

The program would not have been possible without significant input and technology from the center’s information technology (IT) department, notes Chan, who served on the committee that developed the program, along with Jones and the hospital IT director.

"Yes, there were process issues, but they integrated our [electronic] records with registration and radiology," he explains.

Now labs can be drawn by the triage nurse and sent to the lab without a paper requisition attached, Chan says. Because of the electronic medical record system, any physician can place an order on any computer, he says.

"I can order a [complete blood count] on the computer, with no clerk needed to send a requisition," Chan adds. "The nurse can draw the blood, label it with a bar code, and send it to the lab."

The quick registration process had to be initiated first to facilitate the rest of the program, Jones notes.

"Some places can’t do orders at triage and often must wait for the patient to be registered and get a medical number before they can do that," explains Chan.

The ED staff member now provide a bar code at sign-in, and for the 70% of patients who are repeats, they pull the patient’s former record. "We could order anything at triage because we have the [medical record] number," Chan says. Full registration comes later, when the patient is in the room, he says.

Culture change needed

The most difficult challenge in getting staff to accept the new system had more to do with culture than with education, Chan says.

"I think learning the new IT system was the easiest part," he asserts. The culture had to change, and the mentality of triage had to change, Chan says. "The triage nurse used to feel that all she had to do was get through her triage list."

Jones agrees it has been a challenge. "But in the last two years, I’ve seen a major shift in culture; everyone in the department, from a [physician’s assistant] to a physician, now sees flow as a priority."

The ED has a status board that tracks patients and is viewable from computers throughout the ED, including triage, Chan explains. "So [feeling part of the overall flow is] a natural offshoot of the process," he says.

How was this cultural change engendered? There was a lot was persistence on the part of the entire leadership team, says Jones.

"We were all on the same page, with the same goal and mission," she explains. They had a kickoff meeting with staff, talked about it constantly through e-mails and stand-up meetings, and were there with them to facilitate the new process, Jones says.

"We constantly talked about it, posted results, and celebrated when we had good results," she notes. For example, food was provided on occasions, and gift cards for a local restaurant were given to each employee, she notes.

As with any new process, there were some skeptics, Jones adds. "They thought it was just another soup du jour,’" she recalls. "But then they saw we would not let it go away."

Sources

For information on accelerated triage, contact:

  • Ted Chan, MD, Professor of Clinical Medicine, Emergency Medicine, Medical Director, Emergency Department, University of California San Diego Medical Center. Phone: (858) 794-7711. E-mail: tcchan@ucsd.edu.
  • Karen Jones, RN, MS, Director of Emergency Nursing, University of California San Diego Medical Center. Phone: (619) 543-6541. E-mail: k4jones@ucsd.edu.