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Service Delivery Innovation Profile

Team Triage Reduces Emergency Department Walkouts, Improves Patient Care


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Snapshot

Summary

The emergency department at Vanderbilt University Medical Center established a program in which patients are quickly assessed in a triage area by a team consisting of a physician, a nurse, and a paramedic. Patients with urgent problems are promptly moved to a treatment room. Patients with nonurgent problems are tested and/or treated in the team triage area. They are then released or return to the waiting area until test results and a treatment room are available. As a result of the program, most patients see the triage doctor within 10 minutes of arriving, the percentage of patients who leave without treatment has decreased from 5 percent to under 1 percent, and patient satisfaction has increased markedly.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of waiting times, patient walkouts, and patient satisfaction, as well as a matched comparison study of ED bed length of stay.
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Developing Organizations

Vanderbilt University Medical Center Emergency Department
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Use By Other Organizations

A number of hospitals have heard about the Team Triage program and have approached the medical center to request site visits; several have sent representatives to the medical center to examine how Team Triage works, including Massachusetts General Hospital, Barnes-Jewish Hospital at Washington University Medical Center, and University of North Carolina Health Care. The medical center has not conducted any postvisit followup to determine whether or not these hospitals have actually adopted the program.

Date First Implemented

2005
July

Problem Addressed

The number of patients visiting hospital emergency departments (EDs) is steadily rising in the United States, leading to longer waiting times and higher patient dissatisfaction. Many patients leave without receiving treatment, jeopardizing their health and costing hospitals potential revenue.
  • More ED patients, fewer EDs to care for them: In 2003, ED visits reached nearly 114 million, a 26 percent increase over the previous decade. During this time, the United States experienced a net loss of 425 EDs.1
  • Long waiting times: The typical patient spent 4 hours in the ED in 2006, up from 3.7 hours in 2005. Comparisons with earlier time periods suggest even larger increases in waiting times; for example, between 1997 and 2004, the median wait time for ED patients presenting with acute myocardial infarction (AMI) increased by 150 percent.2
  • More leave without being treated: The longer patients wait, the more likely they are to leave without treatment and the less satisfied they are with the ED.3 The Vanderbilt ED experienced all these trends, with rising patient volumes and longer waits contributing to a 5 percent walkout rate.

What They Did

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Description of the Innovative Activity

Team Triage ensures that people with severe illnesses and injuries receive prompt treatment in the ED, while those with less urgent problems are treated and released. The goal is for patients to see a doctor within 10 minutes of their arrival. Key program components include:
  • Quick registration: Arriving patients sign in by providing basic information—such as their name, Social Security number, and chief complaint—to the ED registrar.
  • Triage process: The triage area has three rooms and is staffed by a team that includes a physician, a nurse, and a paramedic. The nurse performs standard triage in one room. The patient then moves to a second room to be seen by the physician, who decides if any tests are warranted and whether immediate care is needed; care is then provided as follows:
    • Immediate care required: If immediate care is needed, the patient is transferred to a treatment room and treated by another ED physician. Typical cases in which immediate care is needed include possible AMI, stroke, or severe respiratory problems.
    • Nonurgent cases, no diagnostic tests required: In nonurgent cases that do not require diagnostic tests (e.g., a sprained ankle, sinus infection, or small laceration), the patient is treated and released.
    • Nonurgent cases, diagnostic tests required: In nonurgent cases that require diagnostic tests, the physician orders the appropriate test and temporary pain relief. (For example, a patient with an injured arm that might be broken would have an x-ray and receive an ice pack, and a patient with a sore throat would get a throat culture.) The patient returns to the waiting room to await the test results. When the results come back, the patient either sees a physician in a treatment room or is released if no further treatment is warranted.
  • Followup registration: The ED registrar conducts a followup interview to obtain billing and insurance information; this interview is conducted in either the waiting room or at the bedside in the ED treatment room, after the patient has received the initial examination.
  • Hours of operation: Team Triage operates from 11 a.m. to 11 p.m.—hours when patients in the waiting room typically outnumber treatment rooms. During offpeak hours, Team Triage is not necessary because patient volume does not exceed the ED's capacity.

Context of the Innovation

Vanderbilt University Medical Center is anchored by Vanderbilt University Hospital, a 600-bed institution in Nashville. The hospital's ED is a Level 1 Trauma Center with 45 beds serving a population of 4.5 million people. The ED treated more than 40,000 people in 2005 and more than 55,000 in 2008. Several days each week, roughly one-half of the ED's beds are occupied by patients who are waiting for a hospital bed to become available. Team Triage was implemented at a time when hospital officials were looking for effective ways to handle the increasing number of patients, especially nonurgent patients who needed to see a doctor but did not need emergency treatment. Such patients often were forced to wait for 5 hours or more before being called to a treatment room, and a significant percentage were leaving without ever seeing a doctor. Vanderbilt University Medical Center developed the program after seeing a conference presentation by officials at Inova Fairfax Hospital in Falls Church, VA, which had established a similar program.

Did It Work?

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Results

Team Triage has reduced the time it takes for patients to a see a doctor from several hours to 10 minutes; the percentage of patients who leave without getting treatment declined from 5 percent to less than 1 percent. Results are as follows:
  • Shorter wait to see a doctor: Most patients see a doctor in the triage area within 10 minutes of arriving, a vast improvement from the old system that often entailed waits of several hours. Those with true emergencies are able to be treated by a physician in an average of 37 minutes.
  • Fewer walkouts: The walkout rate decreased from 5 percent pre-implementation to under 1 percent, which has been maintained since the start of the program.
  • Increased revenue: A hospital analysis has indicated that the increased ED and inpatient revenue due to fewer walkouts totals nearly $500,000 annually.
  • Effect on length of stay: Information provided in 2008 indicated that despite a steady increase in the number of patients (from about 40,000 in 2005 to more than 50,000 in 2007), the total time that patients spent at the ED remained about the same, averaging 358 minutes in 2007. However, new information provided in April 2010 indicates that ED length of stay has recently decreased: a matched comparison analysis found a 37-minute reduction in ED bed length of stay for Team Triage patients, 18 percent lower than that of a matched control group.4
  • Improved patient satisfaction: A survey of patients at 199 EDs by Professional Research Consultants found that after implementing Team Triage, Vanderbilt's ED rose from the 75th to the 95th percentile on likelihood of recommending the ED to others, and from the 80th to 97th percentile on overall quality of care. These results led to the Vanderbilt ED winning Professional Research Consultants' 2007 Gold Achievement Award in Teamwork and Overall Quality.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of waiting times, patient walkouts, and patient satisfaction, as well as a matched comparison study of ED bed length of stay.

How They Did It

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Planning and Development Process

Implementing Team Triage at Vanderbilt University Medical Center required these steps:
  • Facility redesign: The ED was redesigned to create a triage area large enough to comfortably accommodate three patients and a three-person medical team.
  • Rotation of physician staff: Administration identified attending physicians who were interested in working parts of their shifts in triage. Residents were not included in the triage rotation.
  • Initial program implementation: Three physicians were selected to practice with the concept and identify what worked and what did not work.

Resources Used and Skills Needed

  • Staffing: One additional doctor was hired to ensure that the triage area and the treatment rooms had adequate coverage.
  • Costs: The cost of hiring the additional physician for Team Triage has been offset by the increased revenues from the decrease in patient walkouts. The renovation of the Team Triage area cost approximately $40,000.
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Funding Sources

Vanderbilt University Medical Center
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Tools and Other Resources

More information is available at http://www.VanderbiltEmergency.com.

Adoption Considerations

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Getting Started with This Innovation

  • Challenge conventional wisdom about triage: Triage has been performed the same way for 50 years. Patients see triage as a barrier to seeing the physician; therefore, hospitals should consider how triage can enhance patient service. If ED beds are available, then patients can receive treatment in the ED, but when beds are not available, they can be treated in the triage area.
  • Assign attending physicians to the triage role: Team Triage should be staffed by experienced physicians with an interest in this type of care, rather than by a multitude of physicians who are rotating through the role. In addition, Team Triage works best when the triage area is staffed by attending physicians rather than medical residents, who tend to order unnecessary tests that may keep patients from quickly moving to the next step (release or a treatment room).
  • Promote teamwork: Team Triage requires all staff to work together. Promote teamwork by encouraging staff to speak highly of each other when talking to the patients. When nurses overhear a physician talking positively about them, they feel very validated, and the patient feels that they are in very good hands. Departmental successes should be celebrated with the inclusion of all team members.
  • Expect some resistance: Team Triage requires a change in traditional employee roles, which may lead to job dissatisfaction; tips for enhancing staff support include the following:
    • Physicians: Doctors who are used to seeing patients one at a time in a treatment room may dislike the more hectic atmosphere of the triage area. However, if a sufficient number of doctors favor the new system, physicians may be able to choose whether they want to work in the triage area or the treatment room.
    • Nurses: Nurses who are used to making initial triage decisions may be unhappy about relinquishing this responsibility to physicians. There is no magic bullet for dealing with this dissatisfaction, but one can emphasize that Team Triage serves a vital purpose (enabling patients to see a doctor more quickly), that Team Triage reduces nurses' legal liability, and that nurses retain triage decisionmaking authority during offpeak hours.

Sustaining This Innovation

  • Share success: Make sure all staff are aware of improvements that result from Team Triage, such as decreases in patient waiting times and walkouts.

Use By Other Organizations

A number of hospitals have heard about the Team Triage program and have approached the medical center to request site visits; several have sent representatives to the medical center to examine how Team Triage works, including Massachusetts General Hospital, Barnes-Jewish Hospital at Washington University Medical Center, and University of North Carolina Health Care. The medical center has not conducted any postvisit followup to determine whether or not these hospitals have actually adopted the program.

More Information

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Contact the Innovator

Corey M. Slovis, MD
Professor of Emergency Medicine and Medicine
Medical Director, Metro Nashville Fire Department and Nashville International Airport
Vanderbilt University Medical Center
Department of Emergency Medicine
1313 21st Avenue South
703 Oxford House
Nashville, TN 37232-4700
Phone: (615) 936-1315
Fax: (615) 936-1316
E-mail: corey.slovis@vanderbilt.edu

Ian Jones, MD
Executive Director of Emergency Services
Vanderbilt University Medical Center
Department of Emergency Medicine
1313 21st Avenue South
703 Oxford House
Nashville, TN 37232-4700
Phone: (615) 936-0087
Fax: (615) 936-1316
E-mail: Ian.jones@vanderbilt.edu

Innovator Disclosures

Drs. Slovis and Jones have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Russ S, Jones I, Aronsky D, et al. Placing physician orders at triage: the effect on length of stay. Ann Emerg Med. 2010 Jul;56(1):27-33. Epub March 15, 2010. [PubMed]

Govern P. Emergency department lands achievement award. Vanderbilt Medical Center Reporter. June 8, 2007. Available at: http://www.mc.vanderbilt.edu/reporter/index.html?ID=5610

A patient pleaser, 'Team Triage' cuts ED wait times. Hospital Access Management. September 2006.

www.VanderbiltEmergency.com—Vanderbilt Emergency Services [Web site]. Available at: http://www.mc.vanderbilt.edu/root/vumc.php?site=adulted

Footnotes

1 Institute of Medicine. Hospital-based emergency care: at the breaking point. Washington, DC: National Academies Press; 2006.
2 Wilper AP, Woolhandler S, Lasser KE, et al. Waits to see an emergency department physician: U.S. trends and predictors, 1997-2004. Health Aff (Millwood). 2008;27(2):w84-95. [PubMed]
3 Patient Perspectives on American Health Care. Emergency department pulse report. South Bend, IN: Press Ganey Associates; 2007.
4 Russ S, Jones I, Aronsky D, et al. Placing physician orders at triage: the effect on length of stay. Ann Emerg Med. 2010 Jul;56(1):27-33. Epub March 15, 2010. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 30, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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