Implementation of a Vertical Care Area and Enhancement of the Triage Process for Patient Throughput in a Freestanding Emergency Department
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Session G presented Saturday, September 16, 2017
Purpose: The objective of this performance improvement project was to improve the overall triage process and create a vertical care treatment area in the freestanding emergency department to decrease left without being seen rates and improve the throughput experience for patients.
Design: This evidence-based project was nurse driven to implement best practice for patients in a free standing emergency department.
Setting: The setting of this performance improvement project is a 14 bed free standing emergency department in a community outside of Charlotte, NC.
This was an evidence-based process improvement project that did not have a set of participants for study. It was an inclusive project that required all ED staff to participate.
Methods: Design and Implement Project: * Retrieve and compile data for pre-pilot length of stay for discharged patients, left without being seen rates and Press-Ganey overall patient satisfaction scores; * Streamline triage; every RN must take a triage class for uniformity of the ESI level assignment; * Add a Patient Care Partner to assist the triage RN with vital signs and rooming patients; * Use the “Pull till Full” concept of in room triage of patients when there are open beds in the department; * Initiate “Code Triage” if there are 5 or more patients in the waiting room to be triaged; * Creation of 2 Vertical Care beds and 2 lower acuity rooms to improve throughput of ESI level 4s and 5s; * Integrate the use of a rolling triage cart to improve overall triage times, thus decreasing overall length of stay.
Results/Outcomes: A pilot study was initiated over four weeks from 5/6/2016-6/2/2016. There was a decrease in length of stay from 148 minutes to 132 minutes. The left without being seen rate also decreased from 2.44% to 1.24%. Overall patient satisfaction increased from 38% to 93%.
Implications: Key Accomplishments include decreased overall length of stay for discharged patients with a rise in the average daily patient census. Our department exceeded the top box score on Press-Ganey overall patient satisfaction with implementation of a vertical care area and streamlined triage process. Barriers identified include staffing challenges, initial staff buy in and inconsistent ESI triage level assignment prior to all RNs taking a standardized triage class. Another factor of consideration is the continual rise in patient volume. It was identified that Mondays had the largest volume of patients and the highest left without being seen rates. This pilot study was successful and has been adopted as a new practice change. The implementation of a vertical care treatment area is an ongoing project. The next steps for integration and growth include the expansion of the vertical care area, additional staff education on appropriate patients to be treated in the vertical care area and the introduction of a split flow model for ESI level 3 patients that could appropriately be cared for in the vertical care area. In addition the planning and construction of an new triage area is being investigated. This process change has also been adopted at our sister Freestanding Emergency Department, Harrisburg.