Doctor in triage slices door-to-discharge times
Improvements: Turnaround, LWBS, others
Two significant process changes at Methodist Willow-brook Hospital in Houston, have led to dramatic improvements in efficiency, says its ED management team. Consider the following:
- Average door-to-discharge time was cut from more than three hours to two hours and 29 minutes.
- Average time from door to first pain meds was slashed from nearly two hours to 51 minutes.
- Left-before-treatment rates went from 3.3% to 2.3%.
What were those changes? "We put a physician in triage," recalls Kathy Lieder, RN, the ED manager. "At the same time, we blew up’ fast track — which was really slow track."
The fast-track system was replaced with a Mid Care area for nonemergent patients, where RNs assess the patient, blood is drawn, labs are sent, and full registration is completed.
The changes were necessitated by high volume, says Lieder. "We saw 46,000 patients last year," she notes. "This was part of how we survived."
The ED was not meetings its goals for turnaround time, says Patrick G. Woods, MD, MBA, medical director of the ED. "That included seeing and discharging fast-track patients within an hour," he says. "We were probably not even getting them for 35-40 minutes, because that’s when the chart hit the inbox."
Another key issue was the appropriateness (or lack thereof) of advance ordering of X-rays and blood work in triage, Woods reports. "Sometimes they did a real good job, sometimes not," he concedes. "It was all frustrating and bogged us down."
Starting a pilot program
Woods thought that, even independent of how fast-track was (or was not) working, putting a physician up front could be one of the biggest satisfiers and the ED could implement it fairly easily.
"I said, Let’s put a physician up front to see patients right away and to give us the greatest chance of ordering appropriate studies and work-ups,’" he says. So in May 2005, for two consecutive days, he went up front for eight hours.
"We changed nothing else," Woods notes. "I went up there, said hello to the patient, and ordered what was needed."
This initial trial went relatively well, so Woods initiated a full-term trial in July for one week. The waiting room was partitioned in two pieces. One half remained a traditional waiting room, and the other half became Mid Care. "We put two to three nurses there, and we now have a technician and a secretary," says Woods. Mid Care is open 24 hours a day, using three eight-hour shifts. "We start with two nurses," Lieder says. "As we go to staggered shifting, we will have three back there."
In this "best-case scenario," the average time to discharge was 15 minutes, compared to 1.5 hours before the change. The new system went full-time last September, but Mid Care is open only 12 hours a day, Tuesday through Saturday — and 16 hours on Sunday and Monday.
"We front-load the process with the same resources," Lieder explains. "First, the doctor meets and greets the patient and says, I will be the first doctor you see today.’ Emergent patients are sent to a treatment room. Other-wise, after the first orders come in, the patient goes into the Mid Care area, which is located close to radiology," she says. "There, the registrar will fully register them, and the nurses will carry out the orders: X-ray, IVs, pain meds, and so on," says Lieder.
Wood says they built registration into the entire process because gathering too much information got them "bogged down, and nobody wanted to go to the bedside and do registration." The physician was placed directly behind the triage nurse and the registrar, he says. "I can see what’s going on in the waiting room and in the main ED, so I can talk to the charge nurse right away and I can also keep an eye on the registrar."
It is much easier to get sick patients a bed under the new system than under the old, notes Woods.
He gives the example of a patient that may have chest pain and enough factors in their history and/or electrocardiogram (EKG) that you want them placed into a bed right away. "Before, patients were bedded in the ED and in various stages of their work-ups so you were constantly moving people around to make room for sick patients, with really no capacity to add new patients," Woods notes. "Under the new system, many patients are at the end of their work-ups and can much more easily be moved [or discharged] and a new patient bedded that really needs a room."
Woods notes that he’s often asked by nurses about giving narcotics to patients and allowing them to sit in chairs afterward. "Despite comments to the contrary, this is a very safe practice, and it is extremely rare that a patient will suffer an adverse reaction," he asserts. "Moreover, the Mid Care design is such that the nurses sit directly across the hallway from the Mid Care waiting areas and can directly observe the patients in those rooms after administering meds."
Sources
For more information on physicians in triage and Mid Care, contact:
- Kathy Lieder, RN, Manager; Patrick G. Woods, MD, MBA, Medical Director, Emergency Department, Methodist Willowbrook Hospital, 18220 Tomball Parkway, Houston, TX 77070. Phone: (281) 477-1000.
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