So you have decided to embark on a provider in triage and you are building your process for the work area. What form will you choose? In this installment of the patient flow series, we will discuss some of the options that have been successful:
1) Physician triage: This process supplants the triage nurse with a physician. It is commonly stated that patients “come to the ER to see a doctor”. This practice places a physician at the front of the care process. The physician engages the patient on arrival. As vital signs are taken and paperwork is being completed, the physician performs a limited history and physical and initiates care. In a traditional triage model, nursing protocols are utilized to begin care based on a chief complaint. In this model, a tailored care plan is initiated based on the initial encounter with the physician and the patient is then passed along to another physician or advanced practice clinician for the remainder of their stay. This process accomplishes the following:
- The patient is seen immediately by a physician, regardless of complaint.
- Compliance with the “door to provider” metric is improved
- Patient care orders are placed on arrival and there is opportunity to begin care immediately, even in the waiting room
- Care is guided by a physician throughout the visit.
- “Left without being seen” numbers are reduced to near zero. However, “left before treatment completed” numbers may not be impacted greatly.
- The EMTALA required medical screening exam is performed by a physician, on arrival.
- Patient satisfaction is improved by seeing a physician immediately.
This process does not help departments that are under-resourced. Although the patient is seen immediately by a physician, care orders still need to be carried out. In a department without access to sufficient resources, patients will wait lengthy periods of time for those orders to be carried out. This process may actually increase the strain on resources since there is no delay from arrival to order placement. In this case, the total number of patients with pending orders has increased and metrics such as lab order to result, radiology order to result, and time to medication administration may worsen if additional resources are not provided. This structure can be replicated utilizing an advanced practice provider (APP) in place of a physician. However, some of the key metrics improved may not see as significant a change and the effect of “leading” the treatment process is attenuated.
2) Super Track: This process places a team out front. Typically the team includes a provider (physician or APP), two or more nurses, and at least one tech. The team is tasked with caring for all low acuity patients (ESI 4s and 5s) and potentially some of the “vertical” or lower acuity ESI 3’s. These patients are immediately passed on to the team once a triage nurse recognizes them to be candidates based on chief complaint. The team places and carries out all orders while the patient remains in the waiting room or in an adjacent treatment/results waiting area. No bed in the department is required. If volume is high enough, a physician and APP can work together as part of the team. The physician can be the initial contact, placing orders and obtaining the history and physical. Then the patient is dispositioned by the APP after results have returned, based on the plan established by the physician. This allows the physician to continue seeing new patients without returning to the patient for a secondary encounter, unless there is an unexpected result to discuss. This type of plan accomplishes the following:
- Low acuity patients are seen readily, improving the door to provider metric for this population
- Department bed space is only utilized for higher acuity patients.
- Department flow is augmented by providing a results waiting area for this population
- The length of stay overall is positively effected as low acuity patients are seen rapidly and “removed” from the queue. The length of time higher acuity patients wait is reduced due to fewer people in line for a bed.
This process also does not help departments that are under-resourced. However, it does achieve improvements in multiple departmental metrics due to the downstream effects of improved flow and reduced bed utilization for low acuity patients. It is important to note that a low acuity (ESI 4 and 5) volume of at least 20% is necessary for this process to be of benefit. Otherwise, the resources devoted to the triage team will be underutilized.
3) The All-in-one Process: Some departments attempt to perform both functions by asking the team in triage to see everyone AND provide all treatment for the low acuity patients out front. Although this may seem possible on paper, it rarely finds success in implementation. The two functions require different work flows and switching roles with each patient while maintaining focus on what is pending is difficult. For the provider, it is often impossible to see every patient walking in the door of a busy ED and still complete a chart and write prescriptions for patient disposition. For the nurse, triage is time consuming, especially in light of the required documentation for each patient. Adding to it the responsibility of carrying out orders, or educating patients and providing discharge instructions will bring triage to a halt. Pick one of the two processes based on your needs.
A Few Additional Tips:
- Start your process with a handful of physician and nurse champions. They will help provide the necessary feedback, in a constructive manner, to fix initial problems. They will also serve as support when the process is expanded to include all physicians and nurses.
- Point of care testing is an excellent way to reduce process time in the super track. (UA, UCG, limited blood tests, strep, and flu being most common).
- A small automated medication dispensing system stocked with the most commonly used oral and IM meds is very helpful in the super track.
- Scribes are very helpful in the super track when time with each patient is limited.
- Mobile devices for EMR access are helpful for provider efficiency.
- Standard work is important. For this type of project to succeed, each person must understand their role. Variability in the process from day to day will bring this process to a halt.
- Provider in triage is not a 24/7 process. Select your hours carefully so that the project has maximum impact with minimum use of additional staff.
Other helpful resources: