Many emergency departments do not focus resources on lobby triage. This is due, in part, to a misconception that the most influential patient entry point is ED traffic from EMS. This perspective results in strong team members and efficiency and quality strategies being allocated outside of lobby triage. In this post, VEP Chief APC Officer and longtime champion of VEP’s Rapid Patient Management program, Ivan Ventura, PA-C, shares how turning this mindset on its head has a significant, measurable, beneficial impact on door-to-provider times, left without being seen (LWOBS) rates, and patient safety and satisfaction. Ventura has refined this approach at numerous hospitals across the country and knows this: optimizing ED triage from the lobby, especially managing low acuity patients in triage, is one of the most effective methods to improve ED quality and efficiency.
In recent years, the “physician-in-triage” or “provider-in-triage” model has become the standard of care in many industry-leading emergency departments. It consistently improves patient outcomes and reduces wait times, boosting overall efficiency and quality of care. The provider-in-triage model provides an alternative to more traditional, sequential ED processes in which presenting patients are seen by registration staff, a triage nurse, a bedside nurse, and finally, a provider, before being admitted or discharged. Placing a physician or advanced practice clinician (APC) in triage enables EDs to have multiple processes running concurrently, in parallel, thus eliminating unnecessary redundancy and helping patients be connected with the care they need, sooner.
Because we find that traffic through the lobby and managing low acuity patients is one of the most impactful areas to focus on to improve ED operations, we take the basic provider-in-triage model further by working with each of our ED sites to execute our robust Rapid Patient Management (RPM) program which includes not only a provider in triage, but also a full triage team focused on handling as many patient needs as possible before a patient is discharged or assigned an ED bed. We look at the whole process, from patient presentation to admission and discharge, and develop a unique coordinated plan at each site. This requires much more than putting the appropriate team in place. It necessitates ample training and education programs for all ED providers and staff and coordinated efforts with ancillary services to ensure seamless transitions of care.
HOW RAPID PATIENT MANAGEMENT WORKS
Place a Robust Team in Triage
Although we develop a unique plan for each site we serve, we typically staff our triage areas with a strong APC, triage nurses, task nurses, and registration clerks to ensure ample support for Rapid Patient Management execution. Placing this sturdy team in triage to rapidly evaluate and disposition a large percentage of ED patients before they enter the ED has a positive impact on patient safety and satisfaction, provider satisfaction, and the hospital bottom line.
Complete Medical Screening Exams, Earlier
To identify patients with potentially serious problems more rapidly, RPM allows providers to perform the MSE (Medical Screening Exam) as early as possible. As a result, low acuity patients are seen and discharged quickly, while patients that require further workup receive prompt provider-driven orders and treatment. This approach slashes door-to-provider times and left without being seen rates (LWBS), connecting patients with expeditious appropriate care.
Enable Seamless Admissions
The RPM approach extends beyond ED triage to our admission strategy as well. One of the most effective methods we use to enhance the admission process is to participate in, or establish, if necessary, a Throughput Committee to ensure that key personnel and departments are working together to break down barriers to efficient admissions. The Throughput Committee is usually comprised of all the personnel and services that are involved with the admissions process. This can include inpatient unit managers; leaders from the administration, hospitalist service, and ED; case management and discharge planning; inpatient transportation services; and the often- overlooked housekeeping services. The Throughput Committee has a better chance of success when hospital leaders are open to some of the creative, nationally-recognized solutions such as the “Bed-Ahead” program, a transitional care unit where patients waiting for an inpatient bed can be moved instead of waiting in the ED, or a Discharge Lounge where inpatients who are ready for discharge can be moved so ED patients can be admitted.
Optimize Collaboration between ED and Hospitalist Services
Establishing collegial relations between the ED and hospitalist services and developing sensible admission guidelines is another key way to enhance the admission process. These guidelines help to standardize the admission process and reduce delaying tactics which sometimes interfere with admissions. For example, we may establish a guideline that patients not be held in the ED pending the performance or results of time-consuming tests such as CT scans when the results are not expected to affect the immediate management or placement of the patient. We also establish expectations for hospitalist response times, and allow stable patients to be admitted to the inpatient floor when the hospitalist is unable to evaluate the patient in the ED within a reasonable timeframe due to other priorities. We strongly encourage the ED and hospitalist Medical Directors to meet monthly and also attend each other’s staff meetings so that barriers to efficient and safe admissions can be addressed.
WHY RPM IS VALUABLE FOR PROVIDERS, PATIENTS, AND HOSPITALS
Free-Up Bed Space by Discharging Low-Acuity Patients
The RPM model allows a large percentage of low-acuity patients to receive the care they need without entering the Main ED. Patients who may be better suited for an urgent care visit have their needs – whether it be a medication, a splint, or something else – addressed in real time before they ever reach an ED bed. This keeps ED beds available for higher acuity needs and allows Main ED providers to focus on those higher acuity concerns.
Address Higher Acuity Needs, Sooner
When a patient comes in with a higher severity complaint, a provider is immediately available to order complaint-driven tests or medications, such as CT scans or morphine, that nurses may not be able to order. The RPM model enables Main ED providers to have a disposition as soon as the patient enters the ED so that they can immediately intubate or begin a procedure, reducing unnecessary delays.
Right-Size Care to Boost Efficiency and Quality
RPM undeniably connects patients with care appropriate for their needs sooner than more traditional stepwise models. For example, I led this iteration of the RPM program at a hospital that had a LWOBS rate of 14%. Within the first day of using RPM, we discharged 40 patients in one 12-hour shift and our LWOBS rate was 0. In addition to LWOBS, RPM consistently improves nearly every ED quality and efficiency metric, including:
- Patient Satisfaction: Patients get their needs addressed sooner and with less redundancy.
- Patient Safety: Providers can order focused, compliant-driven tests with less lingering time.
- Throughput: Processes run in parallel rather than sequentially, improving throughput and related metrics such as elopement and AMAs.
- Quality Measures: Faster work-ups improve important clinical metrics such as core measure SEP-1 for severe sepsis and septic shock.
At major medical centers where VEP has implemented RPM, the process has reduced double-digit LWBS rates to below 1.0% and significantly reduced door-to-provider times. At several high-volume sites, more than 50% of the patients are seen and discharged via the RPM process, never needing to enter the Main ED, thus freeing up valuable space for higher acuity patients.
HARDWIRING INNOVATIVE TRAIGE PRACTICES FOR SUCCESS
Implementing RPM can be a significant culture change. The start-up of an RPM program is always the most challenging phase and requires leadership support. In order for it to effectively and sustainably improve patient care quality and efficiency, the team must believe in the value of the program. Remember, the team reaches far beyond the triage process to the Main ED providers, adjacent departments, and ancillary services – from IT and infrastructure to equipment and workflow. It is not enough to just put the team in place and define the process. Everyone involved must believe in the process and be equipped with the tools they need to be successful. The two most important ways to ensure buy-in are to provide ample education on the value of RPM to your providers, nursing staff, and administrative staff and to help all providers get comfortable triaging.
RPM BENEFITS PATIENT CARE QUALITY, PROVIDER SATISFACTION, AND THROUGHPUT METRICS
When all personnel and services involved with the admissions process collaborate to build and implement processes, working relationships are strengthened, transitions are more seamless, and culture improves. As long as leaders remain engaged and support teams with training, education, and interdisciplinary opportunities to discuss what is working and what is not, the RPM process is a strong strategy to impact door-to-provider times, left without being seen (LWOBS) rates, and patient safety and satisfaction.