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.

7 Common Patient Waits & How to Fix Them

After supper, a friend told me healthcare gave terrible service.

As a senior management consultant for a well-known multi-national corporation, he spends his time helping companies run well. In his opinion, healthcare runs poorly.

While full of wonderful, caring people, healthcare is inconvenient and inefficient.

7 Waits and How to Fix Them

1. Waiting for appointments with Family Practice – All family docs could offer same day visits. Some physicians have been doing it for decades. Their patients love it, and their practices remain profitable. Some patients want appointments booked days in advance and that should continue. Other patients want to be seen the same day and could be accommodated with on-site urgent-care clinics or advanced access booking.

Patients should never have to wait to see their family doc (or a physician in the practice group).

2. Waiting in the waiting room for your physician – This should be very rare. When it happens every visit, it represents terrible practice management. Physicians run 2-3 exam rooms to prevent patient waiting. If physicians are double-booking because of patient no-shows, then they should collect no-show fines or consider firing patients from their practice who continue to not attend for booked appointments. If physicians are booking too many patients to see them promptly, they need to stop booking so heavily and spread out appointments. They should stop fooling themselves and book a longer day at the office. They are staying late anyways; they might as well do the courtesy of allowing their patients to arrive later instead of making them sit in the waiting room for hours.

Either way, it’s up to physicians to keep their own waiting rooms empty.

3. Waiting for blood-tests and X-Rays – Lab tests can be processed in minutes to hours, but we make patients book separate visits to get blood-work and imagining, then we make them book another visit to discuss the results! Basic blood-work and x-rays should be available same day for all patients. This can be done by allowing advanced access at labs and imaging suites. Digital images can be read off-site.

Patients could receive basic tests and results in the community just as they do in the ED without extra cost to labs and with great savings for patients.

4. Waiting to see specialists. Ostensibly, wait times to see specialists are long because there aren’t enough specialists. However, there’s a glut of unemployed specialists in many fields (e.g., orthopedic surgery, cardiac surgery, etc). Most of the specialists are ‘unemployed’ because they can’t get operating room time. If there really are too few specialists, why don’t they leverage family docs (or unemployed surgeons) in their clinics to screen through their consults and follow-ups?

I worked for a few years as an associate with our local vascular surgeon to churn through his office visits and minor procedures so he could focus on patients needing surgery.

5. Waiting in an ED waiting room – We discuss how to close your waiting room in other posts. It’s the right thing to do – get patients inside, get them seen, get them treated.

6. Waiting for an inpatient bed inside the hospital – There is no reason to warehouse patients in emergency departments. Unless hospitals make a conscious decision to get patients up to the wards, nurses and physicians will not change their behaviour and get patients upstairs. Dozens of papers show that quality and patient satisfaction improve when patients wait in the halls on inpatient wards instead of waiting in the ED. Furthermore, hospitals that send admitted patients up to the wards, when there are ‘no beds available’ on the ward, somehow find a way to put patients into rooms. Staff find a way to discharge other patients to open up space.

Admitted patients should never be left in the ED to wait for an inpatient bed.

7. Waiting for surgery – Patients wait because OR time is limited by OR closures or cancellation of surgery. ORs need to be kept open – after hours if necessary – to treat patients. Surgery must not be canceled because surgical beds are full of medical patients.

Let surgeons manage surgical beds; do not let medical flow issues shut down surgical flow.

Rebuttals

1. If we remove waits, won’t demand go up? Won’t utilization increase? Anxious patients who demand ‘unnecessary’ investigations receive those investigations in the current system. Most average patients don’t want to give blood or get X-Rays and then wait around for results unless they really have to. Average patients would continue to pursue investigations only on advice from their physicians.

2. Wouldn’t MDs start ordering too many tests if they knew they could get same-day results? Sure, more family docs might order blood-work and X-Rays for patients that they presently send to the ED preventing a few ED visits. Same day service would still require hours of waiting for patients; hardly a convenience all patients would want. The current technology for blood-work and x-rays still dissuades frivolous testing because of the time and effort required. Until investigations become as quick and convenient as a medical scan on Star Trek, we won’t see a giant spike in investigations.

Canadians wait politely, and they should not. There’s no need for most of it.

We need to challenge the old way of doing things: waiting for appointments, waiting in waiting rooms, waiting for labs, waiting for x-rays, waiting to discuss results, etc, etc…

We need to adopt a ‘get it done now’ approach all across healthcare.

If you agree, feel free to leave a comment by clicking on leave a reply or # of replies.

Fix Patient Flow Bottlenecks – Forever

Patient flow seems impossible to fix in most hospitals.

Nearly every step in a patient’s journey can stop flow. Even the most LEAN-ed processes require fanatical vigilance to guarantee patients don’t get stopped as they move through our hospitals.

Eli Goldratt popularized ‘bottleneck’ in his classic ‘The Goal‘ – a long narrative presentation of the Theory of Constraints. A worthy read.

Bottlenecks decrease flow.

They cause havoc by showing up unplanned. In industry, bottlenecks turn up as critical processing steps whose maximum speed determines the maximum speed of a whole production line.

In healthcare, bottlenecks change all the time. In fact, a dozen different things could be the bottleneck – the rate limiting step – over 1 day in the ED. During the morning, it’s lack of staff; during the afternoon, it’s lack of beds. Despite this, most folks like to blame their favourite bottleneck:

“If we only had more beds. If only we didn’t have admitted patients!”

“If only we didn’t have such slow docs!”

“If only we had more nurses (or faster nurses…)!”

“If only we had more space!”

If only…

Picking one bottleneck – usually out of our control – removes responsibility to address all the bottlenecks within our control.

In recent posts, we’ve been talking about closing the waiting room, bringing patients straight into the ED and cycling them from chairs to exam tables. These steps bypass the ‘bed block’ excuse most EDs use for making patients wait for hours in the waiting room. Once patients get ushered straight in, dozens of new bottlenecks show up: nursing shift change, waiting for porters, DI/Lab back-up, not enough MDs, patient reassessment delays…running out of patient gowns…

There’s only one way to guarantee a bottleneck will never slow flow in your ED.

Parallel processing

Like putting together an IKEA cabinet, some things need to be done in order. Sequential processing means doing things one after the other – like a long train of boxcars. However, insisting on sequential processing creates hundreds of potential bottlenecks. Parallel processing unhitches the boxcars and lets them all run on separate tracks at the same time. That way, if any process stops, all the others can continue.

Simple enough…

But, medicine loves process. Many of the sacred cows in emergency medicine are core to sequential processing:

Triage followed by

Secondary Assessment followed by

MD assessments followed by

Lab and DI followed by

Portering…

Reassessments…

Discharge

Most providers fight to keep care in a general order. It’s what they’re used to.

A parallel approach looks like this:

Triage (sorting only…more in another post) followed by

Everything else

Easy, right? It’s not.

If you truly adopt this thinking, you might have MDs assess and discharge a patient before the patient even sees an RN. Or, you might have Lab/DI and discharge planning involved before an MD gets to a patient. This requires huge flexibility for providers who’ve been bound by historical process.

But…but…what happens first?

After triage, everything else gets done ‘as soon as possible’. Whoever can get to the patient first, gets started on their part of the process even if it means they can’t complete it before another provider arrives. Get it done, now! Sequential steps can never be tolerated as an excuse for making patients wait.

What bottlenecks are holding you back? What’s holding you back from adopting a fully parallel approach? Share your thoughts by clicking on ‘leave a reply’ or # replies below.