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Format: 04/25/2014

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Urgent Matters E-Newsletter: Patient Intake Best Practices Team Triage

Tuesday, December 15th, 2009

Urgent Matters E-Newsletter
Volume 6, Issue 2

November/December 2009
Special Focus Issue- Patient Intake

Best Practices

Team Triage

It’s said that necessity is the mother of invention; that sometimes the best ideas come from trying to make the most of a difficult situation. That’s certainly the case for Alle-Kiski Medical Center (AKMC) in Natrona Heights, Pa., which hit upon a resource-saving, patient-pleasing triage system while it was struggling with a small, crowded emergency department (ED) and limited resources.

Under the guidance of the ED’s manager, Todd Morando, RN, Medical Director, Jerry Taylor MD, AKMC in October 2008 implemented “team triage,” a why-didn’t-we-think-of-that-before approach to separating the seriously ill from the walking wounded quickly and efficiently. A year later, an ED that was struggling with long door-to-doc times and high patient dissatisfaction has witnessed marked improvement on every front and stretched its limited resources with remarkable success.

At the time team triage was implemented, the 250-bed community hospital was moving about 36,000 patients per year through its 12-room ED. Each bed saw an average of 3,000 patients — twice the industry standard — who more and more were presenting not with injuries and other emergent conditions but with chronic conditions such as diabetes and high blood pressure. These conditions, which required longer workup times, were consistent with the community’s aging population and with the growing problem, known to all hospitals across the country, of patients using EDs as a medical home.

Taylor and Morando were aware that AKMC’s ED staffing service, Canton, OH-based Emergency Medicine Physicians (EMP), had a model for team triage that had been successfully implemented by a number of its clients. They pitched the idea of adopting the model to hospital administrators, who were thrilled at the prospect of providing the ED with some relief.

Lab Work While You Wait

The system is fairly straightforward, says Morando.

“Historically in most EDs, the patient presents through the front door, is triaged by a nurse and then either goes to a room and waits to be seen or sits in the waiting room until a room is available,” he notes. “In that model, the patient sits in the waiting room for hours before coming back, and once they are sent back to an examination room, then they wait for a physician to see them. Only then is lab work ordered, and the patient waits some more for it to be completed before treatment can start.

“In the team triage model,” Morando continues, “the patient presents to a triage window and is seen almost immediately by a nurse and a physician, who assess the patient and determine if lab work is needed. If a room is available, the patient goes back immediately and the lab work is done, but if the rooms are full, the patient goes to a phlebotomy lab right off the triage area for lab work. Using the team triage model labs can be done concurrently with other care.

Implemented from noon to 10 p.m. — the ED’s peak hours— team triage has reduced patient wait times by more than an hour, bringing door-to-doc times to under 10 minutes (well below the ED’s goal of 30 minutes) and total throughput times to two hours. Other timesaving measures implemented by the ED include a fast-track area for patients who can be assessed and treated quickly, and bedside registration for patients whose triage assessment indicates they must be taken to a room for immediate treatment.

Changing A Culture

Selling team triage to administrators was easier than getting buy-in from physicians and nurses, notes Morando, who says AKMC spent six months designing and testing the system as well as educating staff.

“It’s a huge culture change from the way medicine has developed, and every time you have a culture change you have resistance from physicians and nurses,” he says. “To have a physician out front entering in all the work that needs to be done and then sending the patient back to another physician or a physician assistant was a struggle for some of the staff.”

Taylor elaborates. “It’s not the way we’re trained,” he says. “Physicians are trained to do a complete history and examination and to follow through on the patient. It’s a little bit of a challenge to get them to release control of a patient and trust their colleagues and the PAs to follow through. It requires a change in mind set, and it took time for them to adjust.”

It wasn’t any easier for the nurses, Taylor adds. “Traditionally, triage has been the terrain of nurses,” he points out. “I think they thought we’d be in the way out front.”

Education was the key to working out the kinks, in addition to the knowledge that EMP had implemented the system elsewhere with success. “The physicians realized it was a successful endeavor and agreed to give it a try,” Taylor says, “and once they saw how successful it was, almost immediately everyone bought into it.”

While there is a cost to implementing team triage — namely the expense of a dedicated physician for the front of the ED and of PAs for the back — Taylor insists the system is within the reach of any hospital, even those in rural areas or with small budgets.

“We have nothing that we needed to do this,” Taylor notes. “We don’t have an electronic record or computerized physician order entry. We have a grease board and a paper chart. We found ways to work around antiquity.” AKMC recently embarked on a 16-month, $13 million overhaul of its ED that involves physical expansion and revised operational procedures for patients. When completed, the finished renovation will give the ED a total of 25 beds and a fully integrated computerized record system, which will consolidate all of a patient’s records.

Taylor and Morando have no plans to abandon team triage once their ED expands. “We’ll just be that much faster,” Taylor predicts. “Patients come here to see a doctor, so the sooner they do, the better.”

Todd Morando, MBA, MSN, RN, ED Manager, Alle-Kiski Medical Center
Jerry Taylor, MD, ED Medical Director, Alle-Kiski Medical Center

To read more visit the Urgent Matters website .

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