Patient Flow E-Newsletter
Volume 4, Issue 3
July/August 2007
Special Focus Issue-Employee & Patient Satisfaction Affects Patient Flow

Innovations
Streamlining Care Processes: Reston Hospital Center’s “No Triage” Program

All urgent care providers face a common challenge: to assess patients' needs and allocate resources according to the severity of their conditions. This process of triage has evolved over time, and hospitals have developed their own systems to prioritize and manage care. But, faced with crowded waiting rooms and dissatisfied patients, emergency departments (EDs) around the country are looking for new ways to streamline their care processes.

Some EDs follow a "fast-track" approach, opening an alternative urgent care center with a dedicated staff to treat unexpected, but minor, medical cases such as lacerations, ear infections, fevers, or rashes. By fast-tracking the minor cases, staff in the main ED are able to focus on the most seriously ill patients.

Another innovative model has been deemed "no triage," since it attempts to eliminate the initial step during which ED staff perform a comprehensive assessment of patients' needs. Instead, all arriving patients are immediately seen and either treated and discharged, given initial workup or treatment, or admitted to the hospital. Some hospitals have renovated their lobbies and examining rooms to accommodate this approach to care delivery, though physical renovation is not always necessary. Trials of this approach at Reston Hospital Center, in Reston, Va., had impressive results: waiting times fell dramatically and very few patients left without being seen. Although this approach may not be new to some hospitals, Reston is an example of a small hospital that has successfully implemented a "no triage" program and thereby smoothed patient flow and improved patient and staff satisfaction.

ED Gridlock
Reston Hospital is a 180-bed, for-profit facility that sees about 105 patients a day in the ED. More than half of all admissions come from the ED and, during peak times, five or more patients arrive each hour, causing frequent backlogs.

One symptom of the problem was a spike in the number of patients who left without being seen (LWBS). In January, the percent of LWBS patients went from around 1% up to 2.5% of patients. The average length of time before patients saw a provider was 55 minutes. Even though these numbers are low compared with national averages, physicians were unhappy about the situation--and they let the administration know.

"We knew we weren't getting patients in to see providers soon enough," says Teresa Kreider, M.S.N., R.N., Reston's ED director. "There was gridlock in the department, but we weren't able to pinpoint why."

A New Approach
At the Emergency Nurses Association Leadership Conference in February, Kreider heard about the "no triage" approach from a group of presenters from Palms West Hospital, in Loxahatchee, Fla. Kreider, the ED nursing director, and Darren Lisse, M.D., the ED medical director, visited Palms West to observe the program. They were impressed by what they saw, and were eager to try it at their own hospital.

Reston's first "no triage" trial occurred over three days in March. Staff set up an "ED Stat" area near the lobby, where arriving patients were assessed by a physician, a technician, and two nurses. Clinicians were chosen to participate based on their level of experience and desire to get involved.

They generally followed one of three courses of action:

• for minor conditions, such as pharyngitis or urinary tract infections, they treated and discharged patients;
• for conditions such as abdominal pain, extremity injury, and minor surface trauma, they ordered x-rays, blood work, or other tests, then moved patients to a lounge area to await their results and be seen by physicians;
• for the most serious conditions, such as severe abdominal pain, shortness of breath, and kidney stones, they performed an abbreviated history and took initial steps to stabilize patients, then sent them to the main ED.

Under this system, staff members do not have to make independent decisions about which patients need to be evaluated first. Care for all patients begins as soon as possible. Patients spend any down time "in play," waiting for test results or x-rays rather than an initial assessment.

Even though the ED saw high volumes of patients over the three days of the trial, waiting times dropped and no patients left without being seen. The average time from arrival to being greeted by a physician fell from 55 to 22 minutes. Most of the time, the waiting room was empty, except for family members.

"It was clear that patients were much more satisfied," recalls Kreider, "and it was fun for staff."

To capture the learning from this experiment, staff recorded their observations on paper that lined the hallways, touching on issues such as how to handle pediatric patients and the most appropriate shift times. Afterwards, they held a brainstorming session to discuss how the new model had affected operations. Some of the changes were relatively simple, such as moving supplies. But it was also clear that a "no triage" system would require staff to significantly change their work routines.

A Sustainable Model
To explore whether this approach was sustainable, Reston launched a second, longer trial from April 17 to June 3, 2007. Over that time period, the monthly rates of patients leaving without being seen continued to drop, to 0.6 percent in May.

	Total visits	Arrive to triage (mins)	Arrive to bed (mins)	Arrive to leave (mins)	Bed to greet (mins)	Hold Times (hours)	LWBS %
Jan	3161	4.44	35.31	235.89	21.01	1371.2	2.5%
Feb	2741	4.29	26.95	235.25	20.83	1172.4	1.5%
Mar	3317	4.78	31.05	224.71	19.74	1229.5	1.4%
Apr	3198	5.34	25.25	217.79	18.27	950.0	1.1%
May	3461	5.47	15.96	199.22	15.6	861	.6%
Jun	3206	4.80	13.53	199.70	14.76	826	.46%

Patients who needed to be admitted were being admitted faster; others were being treated more quickly and sent on their way. In addition, the number of hours during which admitted patients were "on hold"--waiting to be sent from the ED to another department--dropped, from 1,371 total hours in January to 950 in April and 861 in May. Kreider noted that, under the new system, ED clinicians were able to initiate care earlier and focus on getting sicker patients ready to be admitted. The hospital also created a "holding report" to let directors of inpatient units know if the ED was holding any of their patients longer than 60 minutes. Giving this daily report to directors has helped to bring down the hold times.

Overall lengths of stay in the ED also declined during the trial period, from around 235 minutes in January and February to a low of just under 200 minutes in May.

According to Kreider, the approach at Reston depends on a fully staffed ED; having one physician, nurse, or technician call out reduces the effectiveness for an entire shift. Staff also have to focus on "clearing the bed," admitting patients as soon as possible and discharging others as soon as it is safe to do so.

"In emergency departments, your role is to get the patients to a physician--that's what patients want, that's what physicians want, and that's what safest," says Kreider.

More Satisfied Patients
A "no triage" approach opens up the ED: patients spend less time in the lobby, wondering what's happening behind closed doors. The psychology of waiting holds that people tend to be less frustrated by "in-process" waits--say, for test results--than by initial waits to be seen. Indeed, promptly seeing a clinician has been shown in surveys to be a key determinate of patient satisfaction. Reston generally received few complaints, but during the trial periods they received no negative feedback.

For their part, physicians were happy to be seeing patients more quickly, though there were mixed responses to the new approach. "Some physicians love the system. When they see a patient, they have already had their blood work and other tests done, and they are ready to be diagnosed or admitted," says Kreider. "But some say, 'I don't like you starting my case, I want to start my own case.'"

There was also some initial resistance from nurses. The bottlenecks created by the old system had actually given them occasional down time, during which they hoped to catch up on certain tasks. Streamlining the care processes meant that they were likely to busier for longer stretches.

During the trials, physicians, nurses, and technicians rotated through the ED "no triage" program. Champions of the new system gradually emerged, as they observed empty waiting rooms and the positive effects on patients. "We hope that all staff will see that patients are more satisfied, and come to understand the true value of this project," says Kreider.

Reston continues to fine-tune the model, and may rearrange the ED layout to better accommodate this system. So far, they have added new computer terminals, made space for necessary equipment, and are considering ways to redeploy pharmacy dispensing systems.

Nearby Virginia hospitals have sent staff to Reston's ED to observe the system, and Kreider has been sharing the results of the trials with the members of her local nursing association. "I've been in this business for over 30 years, and we've been doing basically the same process for a long time," says Kreider. "This is an eye opener that there are other ways to do things--to fulfill patients' needs and get things done."

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Teresa Kreider MSN, RN
Director, Emergency Department
Reston Hospital Center