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Triage Model Nearly Doubles Rate of ER Patients Seen Within 10 Min.

Analysis  |  By Christopher Cheney  
   May 17, 2018

An Ohio hospital's provider-in-triage model is generating clinical, financial, and strategic benefits, including lowering its rate of ER patients who leave without being seen.

Grandview Medical Center in Dayton, Ohio, has adopted an optimized version of the provider in triage model for its emergency department, increasing the percentage of patients seen by a doctor within 10 minutes from 38% to 71%.

"This allows a provider to get a first glance at the patient and do a preliminary history and physical. The provider can then put in orders for tests that we can get started in the front while we are waiting on beds in the back," says Nikole Funk, DO, medical director at Grandview Medical Center.

After struggling with a triage bottleneck, Grandview decided to try the provider-in-triage model last summer.

"We do have a high-volume, inner-city hospital, and we had just one triage nurse. The process was to triage one patient at a time, then send patients to the back if a bed was available," Funk says. "The triage process can take about 5 to 7 minutes; so, if you have three patients check in, you can fall 21 minutes behind."

How Grandview optimized provider in triage

Grandview now has a team approach to triage, with a physician and two nurses comprising the provider-in-triage team.

The nursing staff played a key role in launching the provider-in-triage model. "We included the nursing staff and identified a select few who could educate [their peers] and be champions of the process," Funk says.

The select cadre of nurses helped Funk in the early stage of the initiative, which started in July 2017. "I personally worked all of my shifts as the provider in triage to refine the process with selected nursing staff before we brought in the other two physicians who were going to be providers in triage."

Lab work and other testing is crucial in realizing the potential for efficiency gains from the provider-in-triage model.

"We are utilizing the time it takes to get a radiological study or get lab tests done during the time that patients are waiting to see a provider," Funk says.

However, Grandview had to innovate to overcome a challenge associated with testing under the provider-in-triage model.

"Most times, it is the low-acuity patients who get tired of waiting. Even though they may have had labs drawn or radiological tests done, they were sent to a waiting room, and sometimes they leave from there," says Dawn Sweet, clinical nurse manager at the 344-bed hospital.

'Results-pending' waiting room

Grandview's solution was to create a special waiting area for patients awaiting test results.

"We keep patients in the department. We have a results-pending area now; so, our low-acuity patients have their tests completed, go to our results-pending area, and can be discharged from there," Sweet says.

Data reflect patient satisfaction with the provider-in-triage approach at Grandview:

  • Before provider in triage: 1.8%–2.2% left-without-being-seen rate
  • After provider in triage: 1.1% left-without-being-seen rate
  • Patients leaving against medical advice have also fallen, with that rate running at about 1%

"With other institutions that have trialed this process, the left-without-being-seen rate has gone down but the against-medical-advice rate has gone up. That has not been true for us. With our facility, both numbers went down," Sweet says.

"With our process, we have been able to retain nearly all of our patients through the full length of their care. They are not waiting as long for tests and results," she says.

Benefits of provider-in-triage model

Grandview is generating clinical, financial, and strategic benefits from adoption of provider in triage.

In an emergency department, more efficient use of time can save lives and alleviate needless suffering, Funk says. "There have been multiple instances across the country of critical patients waiting in an emergency department waiting room."

The provider-in-triage approach helps emergency departments quickly identify critically ill patients, she says. "We've had some critical diagnoses picked up on patients who otherwise would have been sitting in our waiting room."

The provider-in-triage model has generated at least two financial benefits for Grandview, which is part of the Kettering, Ohio–based Kettering Health Network.

First, the ER has decreased the number of patients leaving without being seen. "Financially, you are capturing all of those patients," Funk says.

Second, word of mouth is spreading across the community, she says. "We have had people come in and say, 'We hear that you don't have a long wait here.' That also increases your revenue."

Strategically, adoption of provider in triage has Grandview well-positioned for the closure of nearby Good Samaritan Hospital. Dayton-based Premier Health plans to close Good Samaritan by July.

"We are anticipating an annual patient volume increase between 20,000 and 25,000 with that closure. Without this new process, we would not have been able to survive. We are already seeing a 10% to 15% increase in patients," Funk says.

She says the provider-in-triage model is a good fit for ERs with high hold hours of patients; high rates of left-without-being-seen patients; and high influxes of walk-in patients.

Christopher Cheney is the CMO editor at HealthLeaders.

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