By Nicholas Metzger, MBA, BSN, RN; Michelle Gunnett, MSN, RN, CEN; Catherine Prante, MSN, RN, NE-BC; Kevin Daly, MD, FACEP; Bruce Friedberg, MD, FAAEM; and Jaime Rivas, MD, FACEP
Editor's note: When the Palomar Medical Center emergency department relocated to a new, state-of-the-art facility in August 2012, the team anticipated an increase in patient volume. However, patient numbers soon rocketed beyond their predictions, resulting in increased wait times for patients.
To meet this new demand, the team decided to redesign its input system. The initiative has resulted in significant increases in throughput and patient satisfaction. The following report is adapted from a poster presented at CEP America's annual conference in September 2013.
On August 19, 2012, Palomar Medical Center (PMC) relocated to a new hospital and new emergency department (ED). The new ED is a Level 2 trauma center, EMS base station and a STEMI- and stoke-receiving facility. Our projected volume included 75,000 annual visits with an admission rate of 23 percent.
The move increased bed space from 29 to 54 beds. The new ED is divided into three pods (A, B and C), each with a care team that includes an MD, PA, RNs, techs and unit secretaries. The design includes a quick view RN and immediate registration. Direct bedding is done until capacity is exceeded, and then secondary triage is implemented.
Quickly upon settling into our new department, PMC saw a sharp rise above our predicted pattern in EMS arrivals and overall daily patient volumes, which in turn led to rising waiting room times, triage delays and an increase in Left Without Being Seen (LWBS) patients.
In an effort to address unforeseen challenges in patient throughput coupled with an above-expected increase in patient volumes, the ED team embarked on a physician/nurse collaborative to combat rising wait times and increasing LWBS patients.
The collaborative, named "Physician In Triage (PIT)," was developed for the new ED and is a shared triage process encompassing a high degree of interdisciplinary cooperation, including buy-in from physicians, nurses, registration, lab, radiology and patients themselves.
Our goal is to provide excellent, appropriate care in a timely manner and in a suitable space to accomplish our Palomar Health mission to "heal, comfort and promote health in the community we serve." It is imperative that PMC identify and implement best practices for addressing emergency department issues of input, throughput and discharge to optimize the patient experience.
The PIT collaborative triage process was designed to improve patient throughput, reduce risks to patients in the waiting room by identifying and treating higher acuity patients earlier and to improve efficiency in delivering care and providing comfort to patients. The goals of the PIT include:
- Improvement in patient satisfaction
- Improvement in quality core measures
- Reduced wait times and ED lengths of stay
- Reduction in unnecessary diagnostic test ordering
- Reduced LWBS patients
Description of Project
The PIT collaborative process successfully addresses the need to evaluate, manage and treat all patients who present to the emergency department in a rapid and safe manner. It aims to reduce the risks to patients in the waiting room by quickly identifying and rapidly treating higher-acuity patients as early as possible when direct bedding is not available in the department.
PIT enhances patient triage assessment as well as patient flow within the ED by allowing patients to be evaluated by an ED physician immediately at the point of triage, when the patient first presents to the department. During peak hours in the department, an ED physician is assigned in triage alongside a team of ED RNs, and together they are able to rapidly assess, identify and treat patients based on acuity, resource availability and department demands.
Adding a physician in triage replaces the practice of the ED RN placing standardized orders for triage and improves diagnostic test ordering and medication management. It also enhances the identification of higher-acuity patients who otherwise may be returned to wait in the waiting room.
PIT requires the entire emergency department staff to have a greater degree of flexibility and is a process more than a location, even though it lives in triage.
Hours: 2–10 p.m., 7 days a week
How Is the "PIT Process" Different than "Standard Triage?"
- The PIT encompasses an entire triage area, not just a triage room. (This includes the Rapid Medical Evaluation rooms, triage rooms, atrium hallway and waiting room)
- The PIT is flexible and adjusts its focus or use to meet fluctuating demands of the rest of the department.
- The PIT staffing typically includes one MD, four RNs, one tech, registration, lab and radiology collaboration.
- The PIT uses ongoing communication and needs assessment collaboration between ED MDs, the ED RN flow facilitator, the ED charge RN and the entire PIT team.
- The PIT has the ability to treat any acuity of patient arriving to ED based on department needs, including those requiring IV medications, inpatient admissions and even stroke codes. However, it primarily functions as a quick-care hybrid unit within the ED.
The PIT Nursing Staff Roles
Quick View RN
- Initial "first eyes" assessment of presenting patient
- Assigns initial ESI level and reason for visit
- Provides initial throughput designation in EMR comment section (ED vs. PIT)
- Consults PIT MD for potential PIT patients
- Performs rapid triage assessment with MD, with priority on highest-acuity patients
- Verifies initial throughput designation and ESI of patient
- Initial documentation of vital signs for all triage patients
- Order management with MD for treatments/tests/labs/meds
- Performs treatments/medication administration for PIT patients
- Manages the patient flow within PIT and waiting room
- Directs and assigns tasks as needed to PIT/triage tech
- Direct beds patients as needed
- Rounds with PIT MD during patient assessments
- Performs ED intake, head-to-toe assessment for all PIT patients
- Completes medication reconciliation for all PIT patients
- Manages PIT rooms/patient throughput
- Completes admit/discharge with PIT MD during team rounding of patient
This newly designed PIT collaborative by PMC emergency nurses and physicians has provided a solution for our emergency department to both prevent and manage department crowding. During its short, five-month inception, the PIT has allowed us to more effectively address ED issues of input, throughput and discharge, thus providing a more optimized patient experience. Four of the five goals the PIT collaborative set out to accomplish have been met or exceeded.
Additionally, our emergency department has realized several unintended benefits of the PIT that have resulted in both an increase and transformation of health system-wide nurse- and physician-led collaborative efforts.
ED Metrics Impacted by PIT Implementation (April–Sept. 2013)
- Overall ED patient satisfaction increased to a high of 86.4 percent, with 8.3 percent increase in "likely to recommend ED."
- Lowest reportable CMS core measures data realized in PMC ED history. Door-to-doctor down 15 minutes, Door-to-discharge down 34 minutes and door-to-admission down 34 minutes.
- 3.14 percent decrease in patients leaving before treatment, including AMAs, since January 2013.
- Patients' satisfied responses regarding "wait time to treatment area" increased 12.8 percent since January 2013.
- ED registration has realized a greater than 35 percent increase in revenue collection from ED patients in first five months of PIT.
The PIT collaborative has been an ongoing, fluid process with several small, incremental changes since its first day on April 1, 2013, all resulting in positive, significant improvements within our emergency department. Staff members have fully embraced the PIT process and regularly offer insight and suggestions for even greater process improvement.
At the time of this project, being in the new hospital for just over one year gave us a narrow view and some limited data; however, the vast improvements in patient input, throughput and discharge are promising trends. These trends appear to have sustained as patient volumes have remained largely unchanged since January 2013.
A key focus moving forward will continue to look at how to implement reductions in unnecessary diagnostic tests, as there is continued room for improvement in this area.
Ultimately, data collection and collaborative efforts will continue, as our primary goal is to consistently review metrics and outcomes and constantly work toward performance improvement and an overall optimized ED patient experience.
Editor's Note: The Palomar Medical Center ED has continued to nurture and refine its PIT initiative with positive results. They are now working on phase II of the project (known as PIT 2.0), which will involve further refining, standardization and recapture of wasted time to continue to improve TAT-D.
The department has maintained its significant gains in patient satisfaction with a mean overall Press Ganey score of 86.1 for the first half of 2014. They have also sustained their improvements in TAT-D and TAT-A, which were reported at 179 and 295 minutes respectively for the first week of July 2014.
Emergency Nurses Association. Position statement: Improving flow/throughput to reduce crowding in the emergency department. Updated December 2010. Accessed July 15, 2014.
Van Dyke K, McHugh M, Yonek J, Moss D. Facilitators and barriers to the implementation of patient flow improvement strategies. Qual Manag Health Care. 2011 Jul-Sep;20(3):223-33.
About the Hospital
Palomar Medical Center is one of the country's largest hospital construction projects and the first new North County hospital in 30 years. The campus has already captured the attention of healthcare professionals worldwide for its use of natural light and space — all designed to speed healing. The new facility offers emergency services, a Level II Trauma Center, cardiology, radiology, rehabilitation services, oncology and imaging. As a non-profit community hospital district, Palomar Health continues its long-standing dedication to treating all patients who need care, regardless of their ability to pay. To learn more, visit www.palomarhealth.org.