ED shrinks LWTs from 8% to below 1.5%

In the course of less than a year, the ED at Potomac Hospital in Woodbridge, VA, has reduced its rate of patients who leave without treatment (LWT) from the 8%-9% range to just under 1.5% — without adding any new staff or hours.

"We just redeployed our assets and used our space in a different fashion," says medical director Luis Eljiek, MD, FACEP, FAAEM.

The key to this improvement is a new greeting process, which is a rapid evaluation unit that involves three individuals; a nurse practitioner who conducts a rapid medical exam; an advanced triage and intervention nurse who can complete a series of order sets; and a triage technician. After the exam, the patients go directly to rooms, where they are seen by a provider and registered at the bedside.

If all rooms are full, the rapid evaluation unit will assess the patients and determine whether they really need a room. If they do, they go to one of the triage rooms. The department has three care areas (minor care, major care, and kids care), and the patients are triaged to one of those areas, based on space availability.

Patients who don't need a room go to the waiting room. Orders are done, and they then sit out in the lobby where they can wait for lab results or radiology studies. When the results are obtained, they are brought to a room and receive final disposition, such as medication, splints, etc.

This final system was the result of some trial and error, says Eljiek. "At the beginning of the year, we looked at rapid triage and started with a doctor out front, but they had to be pulled from the acute care area, so we were robbing Peter to pay Paul," he recalls. "We put the NP out front, did a rapid cycle test, and by June we saw we had cut the LWT in half."

For the first trial, they had some people flowchart the process, performed a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis to see what worked and what didn't, developed a list of items to improve, and divided into groups to address them, says Glenn Sheffield, MSN, administrative director of the ED. For example, notes Inez Johnson, RN, BSN, clinical director of the ED, there was not always a tech available. "I went back to the scheduling process and decided that even if we had to pull a tech from another area, I would do it because we really do seem to be able to run through more patients," Johnson says.

They already had an NP scheduled during that time, so they deployed the NPs out front, says Eljiek. As for the second nurse, says Johnson, "Prior to that, we were budgeted for a second triage nurse as well as a floating nurse for major care, so we readjusted [the assignment of] that triage nurse."

After those adjustments, a new 90-day test cycle was run. By the end of that cycle, the LWT rate was down to 2.5%; in October, it had dropped to just below 1.5%. In addition, average length of stay fell from over 200 minutes to 175 minutes during the same period.