Competitive concerns bring PAs, NPs into triage area
Quality, flow, and patient satisfaction improve
As the old adage goes, "If you can't beat 'em, join 'em." That's exactly what the ED leaders at Harborview Medical Center in Seattle did about one year ago when they noticed the rapid growth of urgent care clinics within local pharmacies.
"Dave [Holt, ARNO, health care specialist lead] came to me about a year ago and said we were having a hard time getting midlevel practitioners because they were working at these clinics," recalls Chris Martin, RN, BSN, ED, director of emergency and trauma services.
The value of the concept itself was reinforced when her husband went to one of these clinics with a sore throat and received a rapid strep test and was "delighted," she says. "We set out to mimic that concept here."
Martin saw no reason it couldn't be done at Harborv-iew by moving physician assistants (PAs) or nurse practitioners (NPs) into triage, and she also saw the potential benefits. "It's a quick way to keep as many as 20-25 patients out of the ED each day, get them treated and happily on their way without ever getting into a bed," she notes.
In addition to speeding patient flow, Martin and Holt agree the new process has improved patient safety and quality of care (because all patients are being treated quicker) while boosting patient satisfaction.
Patients enter the ED and are seen by the triage nurse and the midlevel provider.
"The midlevel practitioner pulls out the appropriate patient and treats them right there," says Holt, who supervises all the specialists in the ED and handles scheduling, human resources counseling, and assignments.
Holt says there is a small area located off of triage where these patients are treated. "In addition to simple conditions like cold, flu, and sore throat, we do have a dental chair so we can do things like I&Ds [incisions and drainages]," he notes.
This setup also helps Harborview improve the care of a patient population that previously was underserved, Martin admits. "We are the only Level I trauma center for four states," she notes. "We average 20 traumas a day and are also seen as a critical care referral center."
As such, she says, the 400-bed facility has almost 90 ICU patients on any given say. "Because of that, it was not that easy to see the urgent care patients," she says, "But those who wait with minor complaints complain the loudest." Thus, she says, the 20 or so patients now seen in triage each day "is a big deal, and from our perspective has been a real success."
This latest move is part of an evolution that has brought health care specialists ever closer to the entry point of the ED.
Holt did an internship at Harborview in 1995. "At that time there were several NPs and PAs who worked on the other side of the building in an urgent care center and handled all the walk-ins," he says. In addition, he notes, these providers were working from 8 a.m. to 8 p.m. That schedule later was extended to 10 p.m., then to midnight, and now they are scheduled to work 24/7.
The ED is remodeling, which eventually will provide seven new beds. However, because of the success of the program, Martin believes the department still will keep the midlevel practitioners in triage.
Holt says having midlevel practitioners in triage has benefitted patient safety, especially because they get to work in all areas of the department. "Because of that, they not only provide excellent care for the minor conditions, but they get a very good 'gestalt' for what else could be wrong in addition to what they see," he notes. "So, for example, in a typical urgent care facility when they see a cough, they will just treat the cough, but since we staff the rest of the ED, we might check to see if there are any risk factors for pulmonary embolism." In fact, he adds, they have admitted patients to the ICU from the fast-track area.
Martin says that while a formal study has not been done, "turnaround time has been much quicker, and we have cut down on the number of patients who leave without being treated." Patient satisfaction always has been good, she says, but Martin believes it has improved because this patient population is no longer waiting to be seen. "They're not competing with people who have abdominal pain," she says. "Patients are being seen and treated. They're not fuming because they have waited so long that they left without being treated."
As the old adage goes, "If you can't beat 'em, join 'em." That's exactly what the ED leaders at Harborview Medical Center in Seattle did about one year ago when they noticed the rapid growth of urgent care clinics within local pharmacies.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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