How focusing on medium-acuity patients helps decrease time to provider and time to discharge and increase patient satisfaction.
It is Monday afternoon. Two cardiac monitors are beeping behind me, worsening my tinnitus. There is an elderly patient moaning, and my nurses keep asking me questions as I'm entering orders in Cerner (our EMR). "It can"t be that bad again," I optimistically tell myself.
Then I realize as I walk toward the entrance that there are four ambulances lined up in the bay, that our beds are full, and that there is a 60-year-old gentleman who has been patiently waiting in the waiting room for three hours to see a doctor.
It is that bad again! Shifts like this made me realize that we had to come up with new ways to serve our patients.
The above scenario is all too familiar in emergency departments around the country, including ours at Sharp Chula Vista Medical Center near San Diego. For much of 2013, our waiting room was packed several evenings a week, and throughput metrics and patient satisfaction were suffering. Despite highly qualified emergency physicians, nurses, support staff and an expanded department with an aggressive triage process, there were still some long waits to see a provider.
The crux of the problem involved the care of our medium-acuity level patients — those designated Emergency Severity Index (ESI) level 3.
At Sharp Chula Vista, as in many EDs, ESI level 3s are the bulk of the patient census and are usually the most difficult to triage and treat. Truly emergent cases (ESI level 1 and 2) are rushed into the ED; lower-acuity patients (ESI level 4 and 5) are promptly served by the Rapid Medical Evaluation (RME) process, which is initiated by the midlevel providers. It is the patients in the middle who usually wait the longest. And in the course of that wait, many of them are end up as higher-acuity patients that need to be seen sooner or lower-acuity patients that could be discharged sooner.
How many times a day do you see a patient in his 50s who may have one or two cardiac risk factors and present with chest pain? The triage nurse labels him as an ESI 3 and may even order a chest pain workup. Come to find out that the patient has had an extensive cardiac and PE workup last week and is really here for his anxiety attack. Triage may or may not pick up the previous history, and after a five-hour wait, he gets discharged with a Xanax refill.
Or how about the anxious 50-year-old male, who is slightly tachycardic but otherwise "stable," who turns out to have a saddle pulmonary embolus?
It's become evident to me that the complexity of these level 3s, who make up the bulk of our patients, is beyond the scope of our triage nurses or our midlevel providers in RME.
Several years ago, I participated in an initiative aimed at supporting medium-acuity ED patients at Harbor-UCLA Medical Center. The program, which was a joint effort between the Los Angeles County and Vituity, leveraged front-end physician coverage to expedite the care of medium-acuity patients. The aim was to is decrease door-to-provider time, initiate an appropriate workup and identify emergent patients that needed immediate bedding.
In the past, Sharp Chula Vista had scheduled a physician in triage during peak times (Mondays), but as our department grew and our census increased, the shift became a full-time ED position.
I felt that the Harbor-UCLA model might be effective at Sharp Chula Vista and brought the idea to my medical director, Andres Smith, and our ED nurse manager, Sharon Rudnick. I was fortunate to also have my assistant medical director, Ran Regev, participate since he had also worked with me at Harbor UCLA on that project. Both Dr. Smith and Dr. Regev have been instrumental in working on this project and leading the change in our group. We partnered with Andrew Smith, our in-house practice management consultant, to work on adding another physician near triage and RME during periods of peak volume.
The goal of the shift was threefold:
We dubbed the process "thriage."
The "thriage" shift currently runs from on Mondays and Tuesdays. The thriage unit consists of a physician, RN and LVN who work together to assess, treat and (when possible) disposition level 3 patients. The program occupies four dedicated patient rooms adjacent to the main triage and RME areas.
Thriage works closely with triage, RME and the front-end staff to get level 3 patients to a physician as quickly as possible so that an appropriate workup can be initiated. Patients are kept vertical when possible to promote a quick room turnover. The physician is also responsible for reading EKGs from triage, answering outside community physician referrals, and during surges, helping the charge nurse bed patients.
Patients deemed unstable or in need of admission and those who will require a more extensive workup are quickly moved to the main ED, while those waiting for results, consults and treatments occupy medical exam chairs near triage (creating a quasi-internal waiting room).
Time goals for thriage include:
Let's take a closer look at how the thriage unit might care for a patient:
A 35-year-old patient comes in with vaginal bleeding. She initially presents to the front window, where she's classified ESI 3 and basic demographics are entered. She's then taken to triage room 1 for vitals.
I start interviewing the patient with the triage nurse. Having determined that the patient is stable, I direct her to my thriage bed, where my nurse orders labs, a pregnancy test and a pelvic exam setup. The exam reveals no further bleeding and the patient is considered stable to wait in either the main waiting room or our internal waiting room. Once the lab results come back, I determine that she is not anemic or pregnant and arrange for an outpatient gynecological follow-up.
The patient is discharged in a timely manner, no bed was needed in the main department and the patient is satisfied because she didn't have to stay very long. My midlevel providers or the main ED physician could have easily seen the patient, but with the crunch on beds and an overwhelmed RME, I am able to reduce the department load and send the patient home efficiently.
Since implementing thriage, Sharp Chula Vista's ED has seen a 25 percent decrease in TTP and TAT-D during peak hours. Length of stay (LOS) has decreased for the entire department, and patient satisfaction scores have risen dramatically.
From a financial standpoint, the program has generally proved budget neutral. Productivity losses caused by extra staffing are offset by increased efficiency — so long as the shift is properly timed to cover peak periods. Initially, we were hesitant to increase physician hours in fear of a reduced census, but as Dr. Regev says, "There are always patients to be seen at Sharp Chula Vista." And this has been more evident since the implementation of the Affordable Care Act on Jan. 1.
Thriage at Sharp Chula Vista still faces some challenges. In my opinion, staffing will be the key to the program's continued success.
The thriage model demands a high level of flexibility from both the physicians and nurses involved. Physicians must be excellent multi-taskers who can manage the department's entire front end while caring for their patients. Both physicians and nurses must be highly collaborative and willing to adjust their workflows as volumes ebb and flow.
Finding the right people for the job hasn't always been easy. Fortunately, a core group of physicians and staff has shown promise in the role. Remember, even though the length of the shift is short (6 hours), it is a fast moving shift with multiple responsibilities. When thriage is staffed with the right group of people, the rest of the department loves it because it really helps relieve the main ED and RME area. And the program has also received key support from the nursing leadership, which has committed to hiring and training nurses in order to improve front-end care.
We also plan to experiment with the shift's timing. To be truly budget neutral, thriage must run only when the ED is at or nearing peak volume. Moving the shift to an earlier timeslot (maybe 1–7 p.m.) may actually be optimal from both a throughput and budget point of view. We have started to do this recently and will be looking at our metrics in comparison with a 3–9 p.m. shift.
Overall, I feel our work on these front-end initiatives has been very rewarding in terms of both the care we provide patients and our growth as a multi-disciplinary team. While work remains to be done, we're confident that we're on the right track.