By Nicholas Metzger, MBA, BSN, RN; Michelle Gunnett, MSN, RN, CEN; Catherine Prante, MSN, RN, NE-BC; Kevin Daly, MD; Bruce Friedberg, MD; and Jaime Rivas, MD
Editor's note: When the Palomar Medical Center emergency department (ED) relocated to a new, state-of-the-art facility, the team anticipated an increase in patient volume. However, patient numbers soon rocketed beyond their predictions, resulting in increased wait times for patients.
To meet this new demand, the team decided to redesign its input system. The initiative has resulted in significant increases in throughput and patient satisfaction. The following report is adapted from a poster presented at Vituity's annual conference.
In 2012, Palomar Medical Center (PMC) relocated to a new hospital and new emergency department (ED). The new ED is a Level 2 trauma center, EMS base station, and a STEMI- and stoke-receiving facility. Our projected volume included 75,000 annual visits with an admission rate of 23 percent.
The move increased ED bed space from 29 beds to 54. The new ED is divided into three pods (A, B and C), each with a care team that includes an MD, PA, RNs, techs and unit secretaries. The design includes a quick view RN and immediate registration. Direct bedding is done until capacity is exceeded, and then secondary triage is implemented.
Quickly upon settling into our new facility, the PMC ED saw a sharp rise above our predicted pattern in EMS arrivals and overall daily patient volumes. This led to rising waiting room times, triage delays, and an increase in patient walkouts (LWBS).
In an effort to address unforeseen challenges in patient throughput coupled with an above-expected increase in patient volumes, the ED team embarked on a physician-nurse collaborative to combat rising wait times and LWBS rates.
The collaborative, named "Physician in Triage (PIT)," was developed for the new ED and is a shared triage process encompassing a high degree of interdisciplinary cooperation, including buy-in from physicians, nurses, registration, lab, radiology, and patients themselves.
Our goal is to provide excellent, appropriate care in a timely manner and in a suitable space to accomplish our Palomar Health mission to "heal, comfort, and promote health in the community we serve." It is imperative that PMC identify and implement best practices for addressing emergency department issues of input, throughput, and discharge to optimize the patient experience.
The PIT collaborative triage process was designed to improve patient throughput, reduce risks to patients in the waiting room by identifying and treating higher acuity patients earlier, and to improve efficiency in delivering care and providing comfort to patients. The goals of the PIT include:
- Improvement in patient satisfaction
- Improvement in quality core measures
- Reduced wait times and ED lengths of stay
- Reduction in unnecessary diagnostic test ordering
- Reduced LWBS rate
Description of project
The PIT collaborative process successfully addresses the need to evaluate, manage, and treat all patients who present to the ED in a rapid and safe manner. It aims to reduce the risks to patients in the waiting room by quickly identifying and rapidly treating higher-acuity patients as early as possible when direct bedding is not available in the department.
PIT enhances patient triage assessment as well as patient flow within the ED by allowing patients to be evaluated by an ED physician immediately at the point of triage, when the patient first presents to the department. During peak hours in the department, an ED physician is assigned in triage alongside a team of ED RNs, and together they are able to rapidly assess, identify, and treat patients based on acuity, resource availability, and department demands.
Adding a physician in triage replaces the practice of the ED RN placing standardized orders for triage and improves diagnostic test ordering and medication management. It also enhances the identification of higher-acuity patients who otherwise may be returned to the waiting room.
PIT requires the entire ED staff to have a greater degree of flexibility. It is a process more than a location, even though it lives in triage.
Hours: 2–10 p.m., 7 days a week
How is the PIT process different from standard triage?
- The PIT encompasses an entire triage area, not just a triage room. (This includes the Rapid Medical Evaluation rooms, triage rooms, atrium hallway, and waiting room)
- The PIT is flexible and adjusts its focus or use to meet fluctuating demands of the rest of the department.
- The PIT staffing typically includes one MD, four RNs, one tech, and registration staff with lab and radiology collaboration.
- The PIT uses ongoing communication and needs assessment collaboration between emergency physicians, the ED nurse flow facilitator, the ED charge nurse, and the entire PIT team.
- The PIT has the ability to treat any acuity of patient arriving to the ED based on department needs, including those requiring IV medications, inpatient admissions, and even stroke codes. However, it primarily functions as a quick-care hybrid unit within the ED.
The PIT Nursing Staff Roles
Quick View RN
- Initial "first eyes" assessment of presenting patient
- Assigns initial ESI level and reason for visit
- Provides initial throughput designation in EHR comment section (ED vs. PIT)
- Consults PIT MD for potential PIT patients
- Performs rapid triage assessment with MD, with priority on highest-acuity patients
- Verifies initial throughput designation and ESI of patient
- Initial documentation of vital signs for all triage patients
- Order management with MD for treatments/tests/labs/meds
- Treats and administers medication to PIT patients
- Manages patient flow within the PIT area and waiting room
- Directs and assigns tasks as needed to the PIT team and triage tech
- Direct beds patients as needed
- Rounds with PIT MD during patient assessments
- Performs ED intake and head-to-toe assessment for all PIT patients
- Completes medication reconciliation for all PIT patients
- Manages PIT rooms and patient throughput
- Completes admissions and discharges with PIT MD during team rounding of patient
This newly designed PIT collaborative has helped our ED to both prevent and manage department crowding. During its five-month inception, the PIT has allowed us to more effectively address ED issues of input, throughput, and discharge, thus providing a more optimized patient experience. Four of the five goals the PIT collaborative set out to accomplish have been met or exceeded.
Additionally, our emergency department has realized several unintended benefits of the PIT that have resulted in both an increase and transformation of health system-wide nurse- and physician-led collaborative efforts.
ED Metrics Impacted by PIT Implementation
- Overall ED patient satisfaction increased to a high of 86.4 percent, with an 8.3 percent increase in "likely to recommend ED."
- Achieved best CMS core measures data in PMC ED history. Door-to-doctor time decreased by 15 minutes, door-to-discharge by 34 minutes, and door-to-admission by 34 minutes.
- 3.14 percent decrease in patients leaving before treatment.
- Patients' satisfied responses regarding "wait time to treatment area" increased 12.8 percent.
- ED registration realized a 35 percent increase in revenue collection from patients in the first five months of PIT.
The PIT collaborative has been an ongoing, fluid process with several small, incremental changes since its first day on April 1, 2013 — all resulting in positive, significant improvements within our ED. Staff members have fully embraced the PIT process and regularly offer insight and suggestions for even greater process improvement.
At the time of this writing, we have just one year of data on which to base our conclusions. However, the vast improvements in patient input, throughput, and discharge are promising trends. These trends appear to have sustained as patient volumes have remained largely unchanged since January 2013.
Moving forward, we will continue to look at how to reduce unnecessary diagnostic testing, as there is continued room for improvement in this area.
Ultimately, data collection and collaborative efforts will continue, as our primary goal is to consistently review metrics and outcomes and work toward performance improvement and an overall optimized ED patient experience.
Editor's Note: The Palomar Medical Center ED has continued to nurture and refine its PIT initiative with positive results. They are now working on phase II of the project (known as PIT 2.0), which will involve further refining, standardization and recapture of wasted time to continue to improve TAT-D.
The department has maintained its significant gains in patient satisfaction with a mean overall Press Ganey score of 86.1 for the first half of 2014. They have also sustained their throughput improvements for both discharged and admitted patients, which were reported at 179 and 295 minutes respectively for the first week of July 2014.
Emergency Nurses Association. Position statement: Improving flow/throughput to reduce crowding in the emergency department. Updated 2017. Accessed April 11, 2018.
Van Dyke K, McHugh M, Yonek J, Moss D. Facilitators and barriers to the implementation of patient flow improvement strategies. Qual Manag Health Care. 2011 Jul-Sep;20(3):223-33.
Originally posted July 25, 2014. Updated April 11, 2018.