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Best Practices: Building Capacity Through Leadership and Accountability
 
In 2006, the Children’s National Medical Center in Washington, DC, was able to reduce arrival-to-triage time from hours to less than 10 minutes. Children were waiting as long as two hours just to be triaged, prompting many families to leave before care could be administered. Staff knew something had to be done, and they hit upon a two-pronged approach: the ESI and rapid triage.

“We were in the throes of LEAN, realizing that we didn’t have to do things the same way we had always done them,” recalls Stacy Doyle, manager of the Medical Center’s Emergency Medicine and Trauma Center at the time. “We started thinking about where our bottlenecks were, about which of our processes were necessary and unnecessary, and about what a visit to our ED had become. We saw a lot of waste.”

According to Doyle, the Medical Center was using a “home-grown” triage system that had five levels but lacked the validity and reliability of ESI. Wait times, the experience and preferences of the nurse on duty, and census pressures all resulted in uneven triage decisions from day to day. In addition, their fast track lacked clear guidelines.
Led by the nursing staff, the ED decided to switch from its own triage system to ESI. It did so for two reasons. The first was to advance the national goal of its parent organization, the Children’s Hospital Corporation of America (CHCA), to reduce length of stay in pediatric EDs by 25 percent. The second was to enhance the understanding of ESI efficacy in the pediatric ED setting. While ESI is widely considered a reliable tool for assigning acuity in the general ED setting, Doyle noted, much less is known about its effectiveness among children. The symptoms children present with can indicate very different things than they do in adults, explains Doyle, giving chest pains and fever as examples of things that are approached differently in pediatrics.

The ED adopted ESI at the same time as a rapid triage process, designed to sort patients to the appropriate ED area based on acuity level. To do this, the triage nurse’s initial assessment was substantially reduced, from a complete nursing assessment including the patient’s weight and a full set of vital signs, to only relevant elements of the history and physical. This brought triage time from 20 minutes to about seven.
 
Using Available Staff
Before the protocol change, patients arriving at the ED were entered into an electronic tracking system and queued for assessment by the next available triage nurse. When the triage area was busy, patients could wait more than two hours to see a triage nurse, increasing the left without being seen (LWBS) potential. Meanwhile, some patients were inadvertently grouped with lower-acuity patients, and their care was delayed.
After the intervention, ESI Level 1 patients were taken directly to a treatment room by any available licensed ED staff member. Level 2 patients were taken to a treatment room by a flow nurse for the collection of data, treatment by a nurse, and an expedited assessment by a provider. Level 3 and 4 patients who did not meet fast-track guidelines were assessed by the triage nurse, and Level 4 and 5 patients who met fast-track guidelines were moved to fast track for a nursing assessment and care.
 
Impact
After the new triage process was implemented, nearly 88 percent of all patients were within 10 minutes of their arrival, as opposed to only 21 percent under the old system. The improvement is even more significant given that, before the adoption of rapid triage, 34 percent of ED patients waited from 10 to 30 minutes for triage, 23 percent waited 30.1 to 60 minutes, and a 20 percent were not triaged until they had been in the ED from one to two hours. The new triage process also affected fast-track use. After adoption, the number of patients triaged to fast track increased from 35 percent to 38 percent, while Level 5 patients were almost 50 percent more likely to be sent to fast track.

While LWBS rates did not change after the adoption of rapid triage—they remained even at 3 percent—the number of Level 3 patients who LWBS dropped from roughly 25 percent to 21 percent, and the number of Level 4 patients dropped from 67 percent to 63 percent. Meanwhile, the number of Level 5 patients who LWBS increased from 7 percent to 16 percent. This means the new system was successful at reaching the sickest patients before they left.

While the triage process change was considered a nursing intervention, the ED physicians, medical director, and administrators were on board as well. “There was no pushback from them,” says Doyle. “We were all moving in the same direction, which was to figure out how to get people through faster and remove obstacles to getting patients to providers.”
The transition cost the Medical Center almost nothing, says Doyle. Approximately 60 ED nurses and a few technicians were trained in ESI during a six-week period. The new triage process used the same physical spaces and equipment, which may explain why other EDs have felt comfortable using it. Since the process was presented to CHCA members, the triage process has been picked up by Children’s Healthcare of Atlanta hospitals at Scottish Rite and at Egleston.
 
Doyle says winning the confidence of the nurses and getting “early adopters” to lead the staff with their enthusiasm will be the biggest challenge for any ED that makes a change in triage.
“It’s harder for them than for the administration and physicians to break from tradition because they get entrenched in what they’re doing,” says Doyle. “We had to get our nurses to go back to the fundamentals of what triage is and why it’s important. More than anything, we needed to redefine our processes to make triage a process, not a place.”
 
Stacy L. Doyle, director of emergency and urgent care services, Children’s Mercy Hospital and Clinics, Kansas City, MO