The problem of ED crowding and its subsequent effect on front-loading aspects of care is a serious problem, which shows no signs of dissipating.8,9 The number of ED visits is rising while the number of EDs available to provide care to those patients continues its steady decline.8-10 Solutions to effectively decrease inpatient length of stay, improve handoffs from the ED to the inpatient units, and provide more efficient inpatient care are detailed in Chapter 40. The adoption of such strategies is just beginning to take hold. Thus, the pace of increase in patient demands continues to outstrip capacity in many EDs. Moreover, as patient visits continue to rise and the primary care physician shortage rises simultaneously, front-loading flow is now and will likely be a necessity to ensure timely, effective, efficient, and safe ED operations.6-10
The bottlenecks of patient flow move and change during the course of a single day, depending upon time of day, patient arrivals, patient acuity, and a multitude of other factors. So the processes utilized too must adjust to meet the changing needs of the patients and providers over the course of time (Figure 32-1).
A great deal has been written stressing the need to reduce variability in healthcare.11-13 A lean-based definition of flow requires a clear understanding that the issue is less the variability itself, but rather that there is variability, which does not add value (or tolerates or increases waste).14 The “Flow Cascade” concept recognizes this essential reality and adapts processes to add value and decrease waste, depending on the specific circumstance of the ED at a particular time and with a particular set of circumstances.
The elements of the “Flow Cascade” include
Triage Bypass/Direct Bedding
Triage bypass was first initiated in the late 1980s at several institutions, including Inova Fairfax Hospital in Virginia and Christiana Medical Center in Delaware. Both of these large volume, high-acuity EDs recognized that there were predictable hours in the morning, typically from about 7am and lasting for a few hours, when there were actually ED beds in which patients could be placed without triaging them. Triage, in effect, was a wasted step, since delaying patients at the triage area added no added value and simply delayed them getting to the nurses and doctors who were waiting to care for them. Dr Robert Cates, the Chairman of the Department of Emergency Medicine at Inova Fairfax Hospital describes the genesis of the concept:
“I was scheduled to give a lecture at a large medical center back in the days when you had to go to the airline ticket counter to get your ticket and boarding pass. I was running late when I got to the airport and was distressed to see the ‘cattle gates' up, in which the ropes force you to go through the ‘maze' before getting to the ticket agent. Fortunately, no one was in line, so I cut around the ropes and went straight to the agent at the counter.
She looked at me and said, “Sir, we have a policy here at this airline that states that I cannot take care of you unless you have gone through the line.” I looked back and there was no line, but having been happily married for a number of years, I take direction from women well. I quickly hustled back around the ropes, entered the maze, and making some left turns and right turns I was quickly back at the same agent, who then smiled and said, “Next!” It suddenly hit me, “That's what we do every morning at triage! We make people go through a maze when there is no need to.”15
Triage bypass effectively recognizes that in addition to not adding value, waste is created when patients are put through a “maze,” going from triage to the waiting room to registration back to the waiting room, only to then be called by the primary care nurse to be taken back to precisely the same open room that they could have been placed in directly from triage.
Triage bypass is also referred to as direct bedding, immediate bedding, mini-triage, direct to room, or “pull until full.”16-19 It requires the ability to do bedside registration but was found at both Inova and Christiana to improve patient turn-around and patient satisfaction while showing no erosion of patient safety.19,20 Triage bypass has been shown to
- Decrease waiting times
- Decrease length of stay
- Decrease left prior to medical screening examinations (LPMSEs or LWOTs)
- Improve patient satisfaction19-22
In fact, triage bypass is a seemingly simple and eminently logical way to ensure that the system is able to front-load flow by getting the patient and the patient care team together quickly, which is precisely what the patient wants.23 However, like any change initiative, there are always “pockets of resistance” to any meaningful change, no matter how logical and well-intended the change may (see Chapter 3).
The primary resistance to change in triage bypass is typically not the triage nurse, registration, the treating emergency physician, but rather the primary care nurse, who perceives a loss of control of his/her rooms, which are now being filled directly from triage by the triage nurse. The traditional system empowers the primary care nurse or the charge nurse to determine when and “when not to” bring patients back to fill the rooms, inherently creating patient care delays.
In effect, this “triage bypass” is a sea-change of control for the primary care or zone nurse and many institutions have found it hard to sustain this change. Nonetheless, it is a highly effective strategy to front-load flow by adding value (getting the patient in a room and seen by the ED team faster) and decreasing waste (avoiding triage and registration), at least during the hours when there are beds readily available. It derives from a simple concept, which nonetheless requires substantial leadership to effectively implement:
“Triage is a process, not a place.”24
Bedside registration has also been utilized since the late 1980s and typically involves an initial rapid registration (often called quick registration or “Quick-Reg”), comprising patient name, date of birth, social security number, and presenting complaint. (Some EDs add vital signs to this list.) The patient is then placed into a patient care room, where, when the patient is not being attended by medical and nursing staff, registration personnel can complete the more detailed process of full registration. This in-room registration is typically accomplished using a “computer on wheels” if terminals are not available in each room. This immediate bedding process allows the staff to immediately begin patient treatment, including ordering lab, imaging studies, and medications either during or shortly after the ED physician and nurse encounter with the patient.24-25 Fundamentally, this concept allows parallel processing of the patient with multiple activities occurring simultaneously, as opposed to the more traditional sequential processing. The majority of large-volume, high-acuity EDs use bedside registration for their patients. When first introduced, it was common for ED staff to resist this “new” change until it was pointed out that just such a process has always been used in EDs to register trauma codes, chest pain patients, and the majority of acute patients arriving by EMS.25 The vast majority of EDs currently use some form of bedside registration.
Advanced Triage/Advanced Initiatives
Triage bypass uses ED beds at those times when they are immediately and readily available and relies on bedside registration to effect the strategy. But once all ED beds are filled, how can flow be front-loaded when there are no appropriate treatment beds? Advanced triage/advanced initiatives (AT/AI) were developed specifically to address those patients, in which the likely diagnostic and/or treatment regimens were known, but in which there were no spaces in the treatment area to begin the evaluation or care. While AT/AIs are also known by many names, they share, a fundamental strategy. Using standardized evaluation and treatment protocols (usually supported by standing physician order sets), AT/AIs allow the nurses at triage to initiate diagnostic, therapeutic or management regimens for specified patients based on presenting complaints and vital signs. Now widely used, AT/AI shortens patient turn-around time and, when combined with appropriate scripts, can be an important contributor to patient satisfaction (see Chapter 11).26 At one point, The Joint Commission (TJC) briefly criticized this strategy on the basis that each and every physician order required prior physician contact with the patient and approval of the order. However, once the self-apparent folly of this approach was pointed out (eg, if a physician is busy with a trauma code and another patient has a cardiac arrest, should the nurse withhold CPR until the physician can evaluate the patient?), EDs quickly turned back to AT/AI as a highly effective strategy.26 Data from multiple reports are clear that AT/AI
- Decreases LOS
- Decreases time to pain relief
- Increases patient comfort
- Decreases time to antibiotic therapy in community-acquired pneumonia
- Decreases time to open artery in chest-pain patients presenting to triage24-27