See How Patient Flow Improved: Mini-Trial of RN-MD Triage

Early Success!

We tried a nurse-physician team with 3 stretchers in our old (empty) waiting room. We did not change our old process; just added a parallel process out front.

An RN met all ambulatory arrivals at the front door for a quick look as before (pre-triage). Ambulance patients came in through a separate process. We ran the parallel RN-MD trial from 10:00 – 13:00.

Process

Patient arrives to see an RN screener/sorter/pre-triage.

Patient directed to an RN-MD team with 3 beds in the waiting room.

Patient sent to registration.

Patient sent home or to appropriate clinical area.

If RN-MD process overwhelmed, patient sent to traditional triage.

At any point, patient sent to acute room as indicated.

Results for 3 hour trial:

30 ambulatory patients seen (less than average volumes?)

Time to see MD = 0 minutes for 27 patients (< 3 minutes from RN screener).

3 patients direct to acute room by RN screener.

5 patients (17%) seen and discharged home by the MD-RN team

3 exam spots added (6% additional capacity) at ZERO cost.

0 left without being seen

0 patients required traditional triage

Reflection

We identified a number of things to improve for our relaunch next week.

Staff who had strongly opposed the trial turned optimistic.

As a team, we had become overly anxious to try new things after a major change ‘failed’ in 2012 (we tried something for 2 1/2 days that didn’t work as hoped). We got a boost today.

We’ll share process detail and performance data as we gain more experience.

Have you tried something like this? Share your thoughts by clicking on Leave a Reply or # replies below.

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?