See What We’re Trying Next to Improve ED Patient Satisfaction, Quality and Flow

So far, we’ve posted what works. In two days, we will try something that (almost) never works.

Does repeated failure mean something is impossible?

Hundreds of teams of really smart people have failed to improve outcomes and efficiency by putting physicians at triage. In some cases, flow did not change. In others, costs were too high. We want to try it anyways.

Why would we bother?

Pros

It’s what we want for our families.

When nurses and physicians need a medical opinion, they go straight to the nearest MD they trust. Direct access. All the non-value added steps removed.

Time equals quality in emergency medicine.

The sooner we diagnose and treat patients, the higher quality of care we can guarantee.

Irresistible.

The chance to radically improve flow and efficiency is just too attractive to ignore. Imagine being able to see and treat even 10% of your patients out front – a chunk of patients would never enter the ED. 30 fewer patients and family members packed into the bowels of the ED seems reason enough to try it.

Fewer steps = lower cost.

If we could exam and begin treatment without a lengthy pre-screen, triage and registration process, we would decrease the number of providers involved and decrease patient length of stay. Staffing costs and length of stay directly impact efficiency.

Parallel processing beats sequential processing.

Modern ED Triage is sequential. It’s guaranteed to become a bottleneck unless an oversupply of staff continually support it. A parallel RN-MD clinical stream right at the front door seems destined to succeed.

Cons

“If it ain’t broke…”

We’ve ranked with the top 3 EDs in Ontario for time to physician initial assessment (PIA) for 18 months. Our average PIA hovers just under 1 hour. However, Voltaire said, “The good is enemy of the best” (approximately). Unless we continually improve, we will slip back.

Everyone failed – why won’t you?

Failed attempts don’t mean something is impossible. As Thomas Edison said, “I have not failed. I’ve just found 10,000 ways that won’t work.” If a concept seems logical and irresistible, it’s worth trying again. Also, St. Joe’s Hamilton seems to enjoy early success with their recent attempt at putting a physician at triage which inspires us to try it for ourselves.

We’ll let you know how it turns out when we try it in 48 hrs. Please share your thoughts below – tell us what we need to know. There’s still time to change what we’re about to attempt!

Emegency Departments That Lag

Time to treatment equals quality for much of emergency medicine. It’s also the easiest way to decide whether an ED is any good. Missed diagnoses, errors of judgment, and clinical mistakes can be hard to spot by comparison.

Emergency Departments That Lag

1. Long Line up at triage –

The most at-risk patients stand in the line-up for triage. Every day, patients walk in with a deadly process inside of them. Until they have been seen, they are unsafe. A line up to be seen is indefensible.

2. Long triage process –

Triage should be sorting; not a primary nursing assessment. Patients need a diagnosis and treatment. In most cases, this means getting patients and physicians together as fast as possible. A long triage process does not add value for patients.

3. Long Line up at registration and long registration process –

Registration – getting a chart made – does not add value for patients; it only delays care. It must be short!

4. Packed waiting room –

There is no reason for patients to EVER wait in the waiting room. Please argue in the comment section below if you disagree.

5. Patients must repeat their story over and over and over.

Providers should quickly check what others have recorded, verify the facts and ask additional questions. Starting over with every provider drives patients nuts.

6. No discharge excellence

Patients should leave the ED with copies of lab and radiology reports, written discharge instructions (if necessary), and clear instructions for follow-up and return visits to the ED.

7. Dismissive attitude

Patients should be welcomed to the ED for ANY complaint. No complaint is trivial for a patient. We – healthcare providers, media, government, all of society – seem to think healthcare would be just fine if it weren’t for all the patients. Besides being unwelcoming non-verbally, there’s a big difference between “Why are you hear today?” and “How can I help you?”

Rules in case you get sick:

Don’t go to your family doc unless you’ve tried something yourself first.

Don’t go to your specialist unless you go to your family doc first.

Don’t go to the ED unless you’ve gone anywhere else first.

Don’t go to the ED unless you are nearly dying.

If you are dying, you shouldn’t go to the ED because we can’t do anything for you…

Excuses

But all our beds are full of admitted patients!

Definitely the most popular excuse, admitted patients definitely make it almost impossible to provide emergency care some of the time. But, even with admitted patients blocking beds, patients should still be brought into the ED and seen on exam tables. If they can wait on chairs in the waiting room, they can wait on chairs inside after they’ve been assessed.

Thankfully, Ontario has started to hold hospitals accountable for getting admitted patients out of the ED, and up to the wards.

Who owns morale?

Management owns operations; staff owns morale. Sure, you can crush morale in even the most engaged staff, but blaming management for staff attitudes will mire an ED in under-performance. Staff control their own morale, and it must be part of performance management.

How does your ED stack up? As a patient, have you researched your local EDs to see which ones to avoid?

What You Need to Know to Improve Patient Flow at Triage

Modern triage = patient sorting + a boat-load of protocols and ‘value added’ steps.

Napoleon’s surgeon seems to be the first provider to try a sorting process for crowds of patients. He wanted to quickly sort which wounded soldiers were most likely to return to battle, so he could provide care for them first. Historical triage got soldiers back into action while seriously wounded soldiers were left to die.

Nice.

In the olden days of emergency medicine (30 years ago), patients could usually be seen soon after registration. They were brought straight in, seen by a nurse and a physician soon after. In the 1990s in Ontario, the ED became a favourite spot to park admitted patients when the inpatient wards became ‘full’ as defined by staff working on the wards.

Around this time, triage turned into primary care nursing for new arrivals and the crowd of patients warehoused in the waiting room.

This was never meant to be.

Triage must be rapid sorting or it’s not triage at all.

Long interviews, multiple forms, medication reconciliation, past medical history, allergy lists, infection control screening, extensive sets of vital signs, patient examination, wound inspection, and answering questions about waits, parking, directions and vending machine locations – modern triage redefined the term ‘triage’.

Maybe that’s a good thing? Surely, all the added work being done by modern triage was started for a reason? Maybe patients want to come to the ED to get a really thorough triage?

NO!

Patients come to the ED to get a diagnosis and treatment. Anything that stands in the way of diagnosis and treatment does not add value for patients.

Triage should add value by getting patients to the care they need as quickly as possible. We should resist anything that stands in the way of patient care. Quality care depends on timely assessment and treatment. Triage adds value only if it facilitates timely care. Triage should never bottleneck flow; there should never be a line-up to see the triage nurse.

We must unload all the duties we’ve piled onto triage, if we are serious about improving patient flow.

If hospitals insist on running waiting rooms like a clinical areas, patients would be better served by assigning nurses to care for the patients in the waiting room instead of shackling triage nurses with non-value-added work.

Does triage add value in your hospital or does it delay care? Is there a patient line-up for triage?

Please click Leave a Reply or # replies below.