Emergency Department Triage Redesign Dramatically Reduces Wait Times, LOS, and Left Without Being Seen Rates

Overcrowding in the emergency department (ED) has been associated with increased inpatient mortality, increased length of stay (LOS), and increased costs for admitted patients. ED wait times and left without being seen (LWBS) rates—patients who present to the ED but leave before receiving a medical evaluation—are indicators of overcrowding.

Mission Health needed to address overcrowding in its ED. The community hospital system confirmed overcrowding when it determined that approximately 4,000 patients were leaving its ED each year without being seen.

Mission implemented an improvement process to address ED overcrowding. The hospital leveraged its analytics platform to develop an ED analytics application that provided actionable, timely ED performance data to focus improvement efforts on four areas: staffing patterns, registration, triage assessment by the registered nurse (RN), and early access to a qualified medical provider.

WAIT TIMES AND HIGH LEFT WITHOUT BEING SEEN RATE INDICATE EMERGENCY DEPARTMENT OVERCROWDING

急诊分诊越来越有助于确保高质量、及时的护理。随着ED容量的增加，等待时间也在增加。急诊科的等候时间和LWBS率是急诊科过度拥挤的指标。过度拥挤与住院病人死亡率增加、住院病人住院时间增加和住院病人费用增加有关。^{1, 2}Additionally, the time from patient arrival to the first contact by a qualified provider plays an important role in ED wait times.³

Mission Health’s Emergency Services includes western North Carolina’s designated Level II Trauma Center at Mission Hospital, select telehealth specialties at regional hospitals with medical direction provided by Mission Hospital-based specialists, ground transportation by Regional Transport Services (RTS), and air transport provided by Mountain Area Medical Airlift (MAMA)—both transportation services can provide transport for neonatal patients.

使命致力于在人们及其家人最需要的时候为他们提供世界级的护理，目的是让每个人都达到预期的结果，首先是没有伤害，也没有浪费，并始终为每个人、家庭和团队成员提供卓越的体验。医院系统的目标是改善急诊护理，作为其努力的一部分，以更好的整体服务。

AN OVERCROWDED EMERGENCY DEPARTMENT CAN’T DELIVER OPTIMAL CARE

Mission identified that the rate of patients leaving the ED without being seen by a qualified provider was higher than it should be, suggesting issues with overcrowding and wait times. Approximately 4,000 patients were walking out of the ED each year. Thispatient safetyissue was negatively impacting the patient experience. In addition to a high LWBS rate, Mission knew the wait time to see a qualified medical provider after triage was also too long, suggesting larger problems with ED throughput.

使命ED的领导层知道他们需要改变，这需要整个团队的参与。医院系统也知道它需要数据来提供及时的、有意义的、可扩展的调整，以提供紧急护理。

ANALYTICS PROVIDES INSIGHT FOR IMPROVEMENT OPPORTUNITIES

Prior to engaging in process improvement, Mission used the Health Catalyst^®Analytics Platform, including the Late-Binding™ Data Warehouse and broad suite of analytics applications for data and analytics to obtain actionable, timely data. Using the analytics platform, Mission developed an ED analytics application (see Figure 1) that provided visibility into ED performance. This included data for patient volume, percent of patients admitted, LWBS rate, door to provider, door to bed, bed to provider, LOS for both admitted and discharged patients, and the longest wait time in the waiting room.

除了ED性能数据外，Mission还将来自成像和实验室的实时数据以及住院床位容量添加到分析应用程序中。这支持了一种系统的方法来护理，并提供了对影响ED吞吐量的部门的状态的洞察。

利用分析应用程序，特派团分析了过去四年的到达和吞吐量数据，建立了基线和趋势，并分析了数据以寻找改进的机会。

IMPROVING EMERGENCY DEPARTMENT TRIAGE EFFECTIVENESS

Mission also used data from the analytics application to identify inefficiencies in the ED triage process: the hospital system reviewed performance for door to triage, time to triage complete, and time from triage to bed. It analyzed physical layout and impact on the ED workflow to determine waste in patient and staff movement.

Mission focused its improvement efforts on four areas: staffing patterns, registration, triage assessment by the RN, and early access to a qualified medical provider.

1. Revised staffing patterns.

To revise staffing patterns, Mission used the analytics application to review changes in patient arrivals over time (using four years of historical data). The baseline review showed that volume varied substantially throughout the year, particularly during specific seasons and holidays. Mission subsequently adjusted their staffing to better align with patient volumes.

2. Improved registration process.

To improve the registration process, Mission instituted quick registration. Registration is a critical component of care, and registration staff must confirm correct patient identification upon patient arrival. Rather than asking a lengthy list of questions that contribute to delays in care, Mission limited triage questions to the minimum required to register the patient and initiate care. To complete the registration process, ED staff now asks remaining questions at the patient bedside during ED stay.

3. Improved triage workflow.

为了改善分诊工作流程，Mission采用了一种基于证据的分诊评估方法——紧急情况严重指数(ESI)®分诊敏度量表——来确定患者的敏度和分诊时的护理优先级。特派团认为，分诊护士最初提出的问题清单太长了。它缩减了问题列表，以确保快速分诊过程和适当护理的安置，将问题限制在那些需要确定疾病严重程度的人。Following triage, patients either moved to an ED room or if not critically ill, may have had to wait for care.

Mission identified the opportunity to improve throughput for patients who were not critically ill, as not all patients who visit the ED need life-saving treatment. The hospital system determined they could make better use of its resources, and speed throughput, for this group of patients. To improve care for noncritically ill patients who are not critically ill, Mission developed an Early Team Evaluation (ETE) protocol to determine which patients may be treated and wait safely in a chair in results pending, rather than a hospital bed. The ETE protocol helps to standardize the decision process for patient placement, bed utilization, and appropriate allocation of resources. While people who are critically ill (e.g., those experiencing chest pain or diabetic emergencies) need to be placed in a bed as soon as possible, other patients are appropriate for the ETE protocol. These patients (e.g., those who may have a sprain, rash, or minor respiratory infection) are ambulatory and can safely remain in a results pending waiting area until diagnostic studies are completed, freeing up the hospital bed for more acutely ill patients.

4. Earlier access to qualified provider.

为了解决患者延迟到达合格的医疗机构进行评估的问题，Mission开发并实施了一个新的角色——分诊高级医师(TAP)。该职位是高级注册护士或医师助理，在分诊区与分诊护士一起工作，帮助减少急诊等待时间。在高峰时段，分诊护士和TAP并行评估患者。为了减少等待时间并提供更及时的治疗，TAP为等待进入急诊科的患者安排诊断检查(如影像学检查、实验室检查或心电图检查)，减少了等待时间并提高了治疗的及时性。

即使有了最好的处理程序，Mission的急诊科仍然会经历难以预测的病人到来高峰。为了确保它能够满足患者的需求，即使患者数量波动，医院系统现在每天下午2点举行跨学科团队护理会议。该团队使用实时数据来确定床和人员的调整，并确定潜在的瓶颈和需要的变化，为繁忙的夜班做准备。负责吞吐量的急诊科和住院部的领导也在每天的开始开会;他们使用分析应用程序来识别可能影响高效吞吐量的障碍，并制定解决这些障碍的计划。

RESULTS

Using a data-driven, systems approach, Mission dramatically improved ED performance in a little more than a year the hospital system achieved the following:

• 89 percent relative reduction in ED LWBS rate, with the current performance at 0.4 percent.
• 85 percent relative reduction in percentage of patients who leave before treatment complete, with current performance at 0.58 percent.
• 75 percent relative reduction in median door to assessment by a qualified provider, with current performance under 15 minutes.

“The use of the analytics and real-time data are key to our success. Without the real-time data, process improvement is like driving without your headlights—you don’t know if you are making positive or negative gains. We would not have been able to improve without the data.”

– Rick Lee, MSN, RN, CEN, NE-BC
Executive Director
Emergency Services

WHAT’S NEXT

该团计划继续采用这种跨学科的方法，以改善急诊工作流程和结果。未来的活动包括将基于团队的护理会议扩大到每天三次，并扩大TAP时间以更好地与高峰利用时间(由分析应用程序确定)保持一致。

REFERENCES

1. Centers for Disease Control and Prevention. (2017).National health care surveys.
2. 太阳,b . C,夏朝,r . Y。韦斯,r·E。Zingmond, D,梁,l . J。汉族,W。,。(2013)。Effect of emergency department crowding on outcomes of admitted patients.Annals of Emergency Medicine,61(6), 605–611.
3. 美国急诊医师学会。(2012)。Standards for measuring and reporting emergency department wait times.

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