Triage in the Waiting Room

By Kay Hall; Erik Egsieker, MD; Toby Higa, PA-C; Jenna Wusz, RN; Josh Henson, RN; Lori Hewitt O’Brien, RN; Chris Modic, RN; Denise Montgomery, RN; and Justin Fillebrown, CNA

When a bottleneck forms around ED triage, wait times increase, frustrations rise, and valuable care may be delayed. Here's how one busy ED improved safety and throughput by moving triage onto the lobby floor. The following is adapted from a poster presented at Vituity's 2015 annual conference.
Adventist Medical Center (AMC) in Portland, Ore., is home to a 32-bed ED that serves over 50,000 patients annually. We're one of only three accredited chest pain centers in Oregon and a nationally recognized leader in treating stroke and cardiac emergencies.
We pride ourselves on having some of the shortest ED wait times in the metro area. However, maintaining efficient throughput became more challenging as our census increased steadily throughout 2014. These higher patient volumes precipitated an increase in diversion hours — a concern for both our hospital and the communities we serve.
Fortunately, AMC had recently committed to becoming a lean organization and had hired two specialists to support the transformation. With their support and advice, our ED formed its own interdisciplinary "lean team." Early kaizen events led to the addition of a dedicated flow nurse and second triage team during peak hours.
While we saw improvement to our throughput and diversion rates, we believed we could be doing even better. Many arriving patients were still waiting longer than five minutes for triage. In addition, the location of our triage area made it difficult for the nurses to perform immediate "eyes on" assessments.
To further enhance throughput, our ED team participated in a two-day organization-sponsored kaizen event involving providers, clinical staff, and support staff.


Following an analysis of our current processes, we decided to enhance safety and efficiency by moving triage into the lobby.
Waiting room triage is a best practice that has helped improve throughput at Vituity EDs around the country. Benefits include timelier assessment, improved turnaround times, and a reduction in patients who leave without being seen.

The team selected 13 members to serve as "champions" for the project. After receiving additional leadership training, these champions oriented their colleagues to the new initiative. Within two weeks, the entire 90-plus-member ED team was fully informed and prepared to act.
The team decided that the lobby triage teams should each consist of a nurse, a registrar, and a PA or NP. This staffing configuration would allow orders to be initiated immediately. Schedules were adjusted to provide additional coverage during peak patient arrival hours. In addition, the project provided impetus for hiring additional PAs and NPs.
Another key task was coordination with other hospital departments. The lean leaders met with managers from lab and radiology to discuss the new workflow. In addition, we held an "open house" to communicate changes to the entire organization.
Next, we needed to create physical spaces that would protect patient privacy during triage while allowing team members to monitor arriving patients. In the short-term, we accomplished this by setting up cubicles and workstations that are used during peak arrival hours.

We also needed a way to orient patients to waiting room triage. To this end, we provided staff with scripting about the process and its benefits. We also placed electronic signage in the lobby to reiterate key points and created an information page for our website.
With the groundwork laid, we were ready to launch. For our first two weeks live, champions were scheduled during peak hours to ensure adequate support for the triage teams. The champions used a skill checklist to verify that all team members were knowledgeable about the process and expectations. They also tracked the number of shifts worked by team members to ensure the process was adequately staffed.

During the implementation period, leaders held weekly team meetings where frontline staff could provide feedback and work together to troubleshoot issues.
Waiting room triage proved very successful in improving throughput at AMC – Portland — even as patient volumes rose throughout 2015.
By August, time-to-provider had dropped to 19 minutes, representing a 40 percent improvement over January. Turnaround time to discharge also saw a modest decrease from 162 minutes to 155.
Best of all, we saw our diversion hours per month drop from 70 in January to 24 by August. By shifting treatment to the front end when appropriate, we'd freed resources to care for higher-acuity patients. The decrease in diversion hours greatly exceeded the targets we'd set for ourselves as well as recapturing valuable revenue for the hospital (an estimated $4,000 per ambulance).

Lessons Learned and Next Steps
Our team is still early in our lean journey, but we've already learned a lot about how to manage change. Some key takeaways:
  • Communicate, communicate, communicate — and then communicate some more.
  • Allow adequate time to prepare staff, but not so much time that momentum is lost.
  • Prepare peer champions to manage resistance and set expectations for success. Everyone should understand that the new process is a work in progress, and that it won’t be perfect on day one.
  • There are always more people impacted by your change than you expect. Be prepared for ongoing problem solving with ancillary services, housekeeping, and other departments that touch your ED.
  • Plan, plan, and while you are implementing, keep planning. Understand that complex changes take time to dial in. Your persistence and flexibility will be rewarded.
We are constantly in the process of refining waiting room triage and plan to continue improving it for the safety and convenience of our patients. Our next steps:
  • We want to renovate our ED to create permanent triage stations. This will eliminate the need to set up and tear down our workstations every day. It will also help us demonstrate compliance with state regulations for triage areas.
  • We also plan to extend our waiting room triage hours so that more patients can be served in an expedient manner.
Since this poster was presented in fall 2015, the AMC Portland ED team continues to sustain its throughput gains — even in the face of steadily rising volumes. They recently extended the hours for waiting room triage. The initiative received a powerful PR boost when a family member of AMC's CEO visited the ED and reported a highly satisfying experience. AMC has agreed to fund the proposed waiting room renovation, which will proceed as soon as plans are approved by the State of Oregon.