A patient pleaser, 'Team Triage' cuts ED wait times
Physician does triage at peak hours
A new process for streamlining patient care in the emergency department (ED) at Vanderbilt University Medical Center has cut length of stay (LOS) by 52% and reduced the number of patients who leave without being seen from 5% to less than 1%, says Brent Lemonds, MS, RN, administrative director of emergency and inpatient medicine.
"Team Triage" — a system that places a physician at ED triage during the peak hours of 10 a.m. to 10 p.m. — essentially follows the theory that if patients don't need to be in a bed, there is no need to have them sit in the waiting room until a bed is available, Lemonds explains.
LOS for Team Triage patients is down to an average of 130 minutes, he says, while the overall figure for those not going through that process was 272 minutes.
"We still have a triage nurse, who sees the patients and then immediately refers them to the physician," Lemonds explains. That replaces the typical linear process of the patient being seen by the nurse and then directed to the waiting room, where nothing happens until a bed is available and care begins, he adds.
With Team Triage, Lemonds continues, a few patients are treated and released almost immediately. For the majority, however, the workup by the physician is started very early, he says.
"The physician is able to determine the appropriate tests and go ahead and get those ordered," Lemonds adds. "He can tell whether or not the patient will need to be in an ED bed for further workup.
"We have some patients who never make it to an ED bed," he says. "They are seen by the physician, he might order an X-ray or a lab test, and they go back to the waiting room until the results come in. Then they are [released]."
In the past, the hospital experimented unsuccessfully with having nurses use protocols to order patient tests upfront, Lemonds notes. "But they can't use a physician's clinical judgment to know exactly what will be needed."
Experience also has shown that it is more effective to put a seasoned attending physician, rather than a resident or a nurse practitioner, at the point of triage, he points out. "The attending physicians typically order fewer tests and don't need to have someone check behind them."
To facilitate the Team Triage process, the hospital redesigned the triage area so that it could accommodate three patients instead of just one, Lemonds says. "That allows the physician to move back and forth between patients."
Another change has been the addition of a technician to assist the physician, he adds. "Blood has to be drawn and patients have to be moved. We're moving some of the back end processes up to the front end."
Registrars, meanwhile, "have to make sure they catch the patients before they get out the door" in order to complete the registration and collect payment, Lemonds says. Aiding that process, he notes, is a discharge station that was already in place.
"We have a two-step registration process that is driven by the Emergency Medical Treatment and Labor Act [EMTALA]," says Laura Roberts, assistant manager of admitting. "Patients come to the front desk and we get eight pieces of data — the bare bones of information — to get [the account] into the computer."
After treatment has begun, or after the patient has had testing done and is back in the waiting room, registrars do a follow-up interview to get billing and insurance information, she adds.
With the faster turnaround provided by the Team Triage process, Roberts says, "the time available to get in and do that interview is greatly reduced. [Registrars] have to work quickly."
Step two of the registration is conducted at the bedside in the ED treatment room, she says, unless the patient's treatment doesn't require a bed. If the patient is waiting for test results, for example, registrars take the person to a cubicle and complete the registration.
"It's a lot of hustling, but it's a good process," Roberts says. "It has improved our patient satisfaction scores."
'It's not cheap'
Team Triage is an expensive option; "It's not cheap to add physicians — but feedback from patients has been good," Lemonds adds. "Most of the patients are tickled not to have to spend a lot of time in the ED."
There have been a few complaints, however, from patients who don't understand why they received an ED bill when they never got to a bed, he notes. "They think it's a room charge."
As for the effect of Team Triage, which was started in July 2005, on the overall cost of providing care, Lemonds says, "We can't tell if it has impacted the financial picture. We don't have great data on those results."
A new process for streamlining patient care in the emergency department (ED) at Vanderbilt University Medical Center has cut length of stay (LOS) by 52% and reduced the number of patients who leave without being seen from 5% to less than 1%.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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