Bedside Triage to Reduce ED Length of Stay
It doesn’t matter what business you are in. Customers expect timely and efficient services. A call center should answer a call by the third ring, a bank customer should be served within two minutes of getting in line, and so on. Hospital emergency departments are no different. When patients present themselves to the registration clerk, they expect to be registered quickly and not to have to wait for long periods to be seen. They do not want to sit in a waiting area for triage (average wait time when treatment rooms are available is four to five minutes) and they don’t want to have to be triaged up front (the average time to triage up front is nine minutes). They want to get back to the room where care will be provided.
Registration generally goes quickly, with only minimum information obtained and an ID band attached to the patient’s wrist. The patient is then usually routed to a waiting area until called by the triage RN and then patient triage takes place. Why does the patient have to wait for triage? Also, does triage have to happen up front by registration or can it be accomplished in the treatment rooms? The answers to these questions will assist the ED in providing more timely and efficient patient processing.
An ED should still have a clinical person up front by registration to quickly assess patient acuity and prioritize patients to ED rooms. This action should happen directly after the quick registration. Once the patient is in the room, registration can be completed and the assigned RN can complete the triage. Since the patient is in the room more quickly, the doctor or care provider has visibility sooner and will visit the patient in the room more quickly. The end result should be a reduction in the overall patient length of stay. The time in the waiting room upfront is now gone and the triage time up front is not needed. Several hospitals have experienced reductions of 10 to 20 minutes from the overall patient length of stay. The doctors really do get in to see the patient quicker.
A well-flowing ED will move patients quickly through the process and either always have a treatment room available or have one available in a short time. Then moving the patient direct from registration to a treatment room makes sense. If all the ED rooms are filled, triage should then happen up front. This is necessary to keep some semblance of flow and also to identify those patients that need treatment immediately.
This effort has been tried in multiple hospitals with good success. It requires good standard work definition, especially when all treatment rooms are filled and some RN training and monitoring. Those EDs with electronic medical records can easily measure the patient’s time to a room and this should be tracked daily by shift to ensure compliance. Many hospitals have this information on the web site as a marketing tool to attract patients. Patients have choices, and they may drive a little farther if they know they can be seen quicker. All EDs should strive to get the patient to the doctor as soon as possible and in doing that, a reduction in length of stay should follow.
This week’s blog was written by Bob Watson, a Senior Associate at HPP. Bob brings many years of experience in process improvement and healthcare to the HPP team. He has successfully conducted Kaizen events throughout the Emergency Department, registration, floor units and operating rooms to reduce ED LOS by over 2 hours, reduce registration errors by over 50%, and reduce floor admit time by over 2 hours. He has designed and implemented Electronic Patient White Boards providing visibility to the floor units and administration resulting in better managed patient Length of Stay. Bob’s prior experience includes Juran Institute, Inc. where Bob served as Vice President. Prior to joining Juran, Bob was the founder and principal of Watson Associates, a consulting organization that provided inventory management and engineering solutions to repetitive and high technology manufacturers. He also worked with GTE Sylvania Lighting’s Logistics operation and had a 17-year career with General Electric. Bob has developed training for lean, six sigma and DFSS. He received a BS and MS degree in Industrial Engineering at Rensselaer Polytechnic Institute.