• By Eliminating Triage, St. Lucie Reduces ED Waits, Boosts Volumes

    Feb 20, 2012

    By Lola Butcher

    St. Lucie Medical Center has done away with two accepted ED practices: triage and waiting room registration. The results suggest that these may be practices worth reexamining.

    There is nothing like a long stay in an emergency department (ED) waiting room to make a bad impression on patients and their families.

    "Patients will always see a delay in care as a big problem, no matter how well the physicians and nurses treat them," says Michael Meloni Jr., MD, ED medical director, St. Lucie Medical Center, Port St. Lucie, Fla. "The opportunity to create a great patient experience has been lost long before the doctor gets to the patient."

    In 2007, St. Lucie embarked on a redesign of its ED processes-which included eliminating triage and implementing bedside registration-to reduce wait times and increase patient throughput. Historically, ED patients had waited nearly an hour, on average, to be placed in a bed. Now, the average wait time at St. Lucie's ED is about nine minutes. Other performance metrics have also improved.

    • Door-to-doctor time (how fast patients see a physician) decreased from 66 minutes in early 2007 to 20 minutes by mid-2008, and currently averages about 12 minutes.
    • The left-without-being-seen rate (the percentage of patients who leave the ED before seeing a nurse or physician) decreased from 6.3 percent in early 2007 to fewer than 0.2 percent by mid-2008-and the hospital continues to maintain that rate.
    • By decreasing ED wait times and opening up ED beds, patient volumes increased by 15 percent in the first year.

    Eliminating the "bank teller" approach, in which patients lined up to be registered before any care was given, also improved patient satisfaction, and even though registration now occurs in patient rooms, the process is just as effective. There has not been an increase in administrative denials or a reduction in point-of-service collections since transitioning from upfront registration to bedside registration, he adds.

    "Before our redesign initiative, it may have seemed to the patient-who is sick and looking for care-that the most important part of their ED visit was for the hospital to get their insurance information," says Meloni. "It's now obvious to the patient that their health care is the priority of all of the people involved in their care."

    Addressing Patients' Needs Immediately

    The main goal of the initiative was to streamline processes so a patient's evaluation and treatment is started immediately on arrival at the ED. As a result, patients are no longer triaged in the ED and are instead brought to a room, according to Meloni.

    "Instead of being asked to fill out a form that asks why they are there, who their doctor is, and what their meds are, patients are now brought directly back and put in a bed, where they are greeted by a nurse," he says.

    The nurse gathers the basic information needed to access the patient's electronic medical record and uses standard protocols that correspond to a patient's complaints. For example, if the patient complains of abdominal pain and vomiting, the nurse immediately asks a physician to authorize medication and a blood draw.

    "The doctor comes over, greets the patient, finds out exactly what's going on, and puts in whatever other orders they want to put through. So we are immediately addressing the patient's needs," he says.

    If all ED beds are full, the patient is escorted to the "subway"-a small room near the front door of the ED where incoming patients can have their symptoms treated until a full evaluation and treatment is conducted once a bed becomes available.

    "We draw blood, we perform an EKG or give IV fluids, if necessary, or we give anti-nausea medicine to give a patient some relief," says Meloni. "This shows patients that they are actually being treated for the reasons that they came to the ED."

    Streamlining the Registration Process

    After patients are escorted to an ED bed or the "subway," a registrar comes to the bedside with a computer on wheels to register the patient and collect insurance copays, if applicable.

    A computer tablet is used to capture patient signatures, eliminating a traditionally paper-based process. "Data capture is just as accurate with bedside registration as it is in traditional upfront registration," says Meloni. He cites three specific benefits of bedside registration:

    • Decreases the amount of time a patient waits to see a physician
    • Increases the patient-friendly factor: Patients feel that their care is the top priority for the ED staff because they are not asked registration questions until after they have been evaluated and treatment has begun
    • Reduces registration staff: Because registrars are not tied to a desk, fewer staff members are needed to handle the workload

    The registrar must be flexible and sensitive to care processes so that registration does not interrupt the patient's interaction with a member of the clinical staff. "Registrars understand that getting the registration information should take second priority to anything that has to do with patient care," says Meloni. "I've had a number of registrars back out of rooms when I walk in or when the nurse walks in."

    In approximately 80 percent of cases, registration is completed at the patient's bedside. However, for short ED stays-for example, a patient who does not require any images and needs only a prescription filled-registration is completed at the time of discharge.

    "The patient literally has to pass through the registration area to get out the door," says Meloni. "The registration clerk makes sure we have all the information needed and asks the patient for any copay that is necessary or outstanding balance that is due."

    Identifying Improvements from Within

    Meloni says specific ED process improvements must be identified and implemented by the people who work in the ED or support that work. St. Lucie hired lean performance improvement consultants to guide an ED redesign team that included nurses, ED physicians, registration staff, and others. The team studied the existing processes, recommended opportunities for improvement, and devised new processes.

    Lola Butcher is a freelance writer and editor based in Missouri.

    Interviewed for this article:

    Michael A. Meloni Jr., MD, is emergency department medical director, St. Lucie Medical Center, Port St. Lucie, Fla. (DrMike54@aol.com).