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Patient Flow Enewsletter Best Practices As private and public hospitals struggle to serve more patients with fewer resources, emergency department (ED) overcrowding and patient throughput issues are a primary focus for hospitals across the country. Hospitals commit huge amounts of time and resources to devising solutions to ease throughput problems. One such hospital, St. Joseph Medical Center in Towson, Maryland, built a bigger, state-of-the-art ED in November 2004 believing that would solve their throughput problems, only to find patient flow indicators did not improve. A community not-for-profit hospital with 308 beds, St. Joseph sees 41,000 patients per year in the ED and serves parts of Baltimore and surrounding northern suburbs. Although structural improvements did not solve St. Joseph's throughput challenges, a process improvement throughout the institution - including changes in the ED and other departments like housekeeping and radiology - led to great success. Joseph Twanmoh, M.D., F.A.C.E.P., President, Resources Consulting and Assistant Professor, University of Maryland School of Medicine, spoke to Urgent Matters about the triage bypass initiative that helped improve patient flow in St. Joseph's ED. He worked at the hospital as a consultant and helped implement the triage bypass system. Triage Bypass In hospital EDs, patient flow begins at triage. Patient assessment should be rapid and accurate to provide efficient emergency care. However, when every patient in a busy ED must be evaluated by a single triage nurse before being assigned a bed, a bottleneck in patient flow is inevitable. Such was the situation at St. Joseph. Because massive improvements had just been made to the ED, it had the attention of senior management. "Since this project was part of the larger hospital-wide initiative," said Dr. Twanmoh, "management was already supportive. We decided to focus on the registration and triage system for several reasons. First, the waiting time to see a physician is a key measure of patient satisfaction. Second, improving "door to physician time" would maximize already existing bed capacity. Third, it was a process which was largely under ED control and didn't require a lot of outside buy-in, which is the first, and essential, step in making something like this work." Noticing that the registration and triage system could be improved, the hospital tried a bedside registration system, but did not see much improvement in patient flow. Consequently, Dr. Twanmoh and the ED team's next step was to develop the triage bypass system.
In St. Joseph's previous triage and registration system - a very traditional one - patients arrived, went through a "mini registration," which was just enough to get them into the system, were evaluated by a triage nurse, and then sent back for full registration. The patient's chart then went to the charge nurse for bed assignment. After being assigned a bed, the primary ED nurse would perform a nursing assessment in addition to the triage assessment. The chart would finally be placed in the "To be Seen" rack to await physician evaluation. When beds were available, this process could often take 45 minutes or longer. Implementation Dr. Twanmoh says the advantage of this system is its reliability. "Fast track patients can usually be determined by age and chief complaint. Someone who is 55 with chest pain is clearly not going to fast track," he points out. Another advantage is that there is no additional risk to the patient if triage is bypassed. If a patient is placed in fast track and is found to be sicker than originally thought, the patient is simply moved to the main ED. "Being quickly assessed in a treatment bed is better than sitting in a waiting room not receiving any care," he says. St. Joseph's triage bypass system was so successful, that it went straight from the pilot phase into implementation. "We did make some adjustments during the pilot phase - sometimes patients ended up in fast track that weren't supposed to be - but we monitored the system closely, gathered feedback from patients and made adjustments accordingly," said Dr. Twanmoh. Although the new triage bypass system was a cultural change for staff, it quickly became the cultural norm in the ED. "It was an adjustment for staff - beds were turning over much more quickly than before. Staff used to get a little break between patients because there was lag time in getting patients back to beds. That lag time is gone now, but it is making our patients happier," said Dr. Twanmoh. The new system did not require any additional staff training, just major changes in day-to-day business in the ED. Triage bypass is always in place in St. Joseph's ED, but stops when all beds are full. When this happens, the computer system is able to track patients who are waiting to see doctors. Staff can easily see who is waiting, even if they have not been formally triaged yet. Results To measure the results of the new system, Dr. Twanmoh and the ED team looked at door-to-bed time, door-to- provider time, and Urgent Care (UC) overall length of stay.
Goal Numbers:
Lessons Learned "Triage Bypass is an effective mechanism to expedite patient flow into the ED, but is not a stand alone solution. Any project like this should be a part of a bigger plan to improve patient throughput, with the support of senior management being vital to success. Hospitals need to look at all aspects of patient flow throughout the system, not just the ED. One needs to think in parallel as opposed to sequentially when changing process," Dr. Twanmoh says. "Everyone is looking for a magic bullet for patient flow, but there is no quick fix." Dr. Twanmoh also reminds us that, "Quality has no finish line. If you're successful, more patients will come, which increases volume, making readjustment necessary. You must always monitor your progress and readjust accordingly." ------------------------------- Responses to Your Questions Q #1: There is a great description of the "old system" but where are the details of the bypass system? What exactly was the change? Conceptually, triage bypass operates on the assumption that patients do not need to be triaged in the traditional sense when beds are open and available. For some unknown reason, ambulatory (walk-in) patients have been subjected to the triage process outside of the treatment area, typically in an area off of the waiting room, before they are allowed to cross the threshold of the treatment area. Conversely, ambulance patients are sent directly to a bed with minimal information exchanged between EMS provider and ED nurse. Once in a bed, the nurse performs an initial nursing assessment that we now call 'triage'. In a practical sense, the change that was implemented was that we now treat both ambulatory and ambulance patients the same. If there is an open bed, the patient is taken to the treatment area and the initial nursing assessment (a.k.a. triage) occurs at the bedside instead of in the waiting room. In this particular ED, there are essentially two treatment areas, Urgent Care (fast track) and Emergent Care. The critical decision is to which area the patient should be directed. Based on chief complaint and age, patients are sent to one of those areas. Vital signs are not taken. If a patient is sent to fast track and turns out to be more acutely ill than initially thought, the patient is simply moved to the emergent care side. Either way, the patient is better off than sitting in the waiting room or the triage office. In addition, we created a push/pull system where the triage nurse could "push" patients into open beds, and the rest of the ED staff was empowered to "pull" patients into their beds without waiting for the triage nurse to assess the patient. Q #2: What happens when beds are not available in the ED? When beds are not available in the ED, the traditional triage process is activated. It is at that time that triage serves a vital function. The triage nurse literally has to decide which patients get immediate treatment and which ones can and must wait. However, beds open up sooner than one might think, particularly in fast track where beds are always turning over. What commonly happens is that multiple patients arrive simultaneously. For example, the lone triage nurse has five patients to triage: one with chest pain, one with abdominal pain, one who is weak and dizzy, one with an ankle injury, and one with a sore throat. A good triage nurse will look at the chief complaints of all five patients and probably eyeball the five patients as well. If the triage nurse has to evaluate all five patients, guess which patients will be last to be triaged? More importantly, patients will continue to arrive bumping the lower acuity patients to the back of the triage line. However, if there are two beds open in fast track, the ankle and sore throat could go directly there, bypassing triage. The triage nurse is saved from triaging two patients, the waiting room is less crowded, and more importantly the patients are evaluated, treated, and discharged sooner. Q #3: How do you factor in getting admitted patients up to their beds on the floors or in telemetry, etc.? This question implies that it would be difficult to place a patient in an empty bed because that nurse is out of the department transporting the admitted patient upstairs. The short answer is that one needs to build in a backup system for your nursing staff. One strategy that I have successfully used is patient care teams, where two nurses, one ED technician, and a physician are responsible for an assigned group of beds within the ED. When the one nurse leaves to transport the admitted the patient, the other nurse receives the new patient. I have also seen where the charge nurse is the backup person. Some Emergency Departments have the luxury of a float nurse. Whatever strategy one uses, it is important to fill the empty bed as soon as possible. Q #4: What is the use of Urgent Care Centers in your area? Do you think this would affect your ability to implement the triage bypass? There are several Urgent Care Centers in the immediate area, as well as a competitor hospital less than a mile away. I do not believe that this would have any impact on the ability to implement triage bypass. Triage bypass is simply eliminating unnecessary steps in the process of getting the patient to a treatment bed. ------------------------------- Joseph Twanmoh, M.D., F.A.C.E.P. | ||||
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