Optimizing Emergency Department Throughput with Improved Triage Processes

Abstract

Evidence-based Practice Abstract Purpose: Triage processes in the emergency department (ED) have a significant impact on patient throughput. Efficient ED throughput is vital to provide safe and high quality patient care and to prevent ED overcrowding. The purpose of this project was to develop better flow processes at triage to eliminate the significant delays occurring at triage and to improve ED throughput. Design: Implementation of a unit based process improvement project developed by an ED process improvement team. Setting: The setting is a rural community hospital emergency department with an annual volume of 32,000 patients. The emergency department has a total of 18 beds with 12 beds dedicated to more acute patient conditions and 6 beds dedicated to less acute patient conditions. Subjects: The process improvement project focused on all non-ambulance patient arrivals. Methods: The methods for success included committed bedside nursing champions and committed and experienced ED nursing and physician leadership, strong support from the administrative team, shared visions, specific goals, availability of daily statistics on ED throughput, encouragement of all ED team members input into new process development, education, and continuous feedback and problem solving. The ED process improvement team identified barriers to throughput at triage and developed new process improvements using a direct bedding triage model with complete bedside registration and triage protocols. Upon arrival, patients receive a quick registration and are asked their chief complaint, height, weight and allergies and then are immediately placed into an ED treatment area. All ED treatment areas are utilized and when the emergency department becomes saturated with patient volume, three additional treatment bays are now able to be utilized in an outpatient area located adjacent to the main emergency department. Triage protocols were developed and implemented to expedite the initiation of patient care by nursing when providers are unable to immediately place orders. Mandatory education for all ED staff was completed by the bedside nursing champions. Results: Within the first year of directly bedding patients, implementing triage protocols, and utilizing all ED treatment bays, many improvements were made, including patient arrival to the bed placement decreasing from a mean of 13 minutes to 3 minutes, door to provider exam times decreasing from a mean of 23 minutes to 13 minutes, the left without being seen (LWBS) rate dropping from 0.5% to 0.2%, door to discharge times decreasing from a mean of 110 minutes to 102 minutes, and patient satisfaction scores increasing from 33% to 75%. Implications: Designing methods to improve flow that begin upon patient arrival to the emergency department will have a multitude of positive effects thus improving ED throughput and reducing LWBS rates. Patients are more satisfied with their care because they are being examined, treated, and discharged quicker. Involving bedside nursing leaders in the design process engages nurses to make improvements and to support their colleagues’ throughput a process change.