PRACTICE IMPROVEMENT

IMPROVING PATIENT FLOW IN THE EMERGENCY DEPARTMENT BY PLACING A FAMILY NURSE PRACTITIONER IN TRIAGE: A QUALITY-IMPROVEMENT PROJECT Authors: Crystal Hayden, DNP, MSN, RN, FACHE, Penney Burlingame, BSN, RN, DHA, FACHE, Holly Thompson, MD, and Valerie K. Sabol, PhD, ACNP-BC, GNP-BC, Jacksonville and Durham, NC

ith inefficient front-end operations, emergency departments across the country are experiencing increased wait times, increased rates of patients who left without being seen (LWBS), and decreased patient satisfaction. Workforce shortages of emergency medicine physicians coupled with poor access to primary care dictate the need for hospitals to consider advanced practice providers (APPs) as a potential solution to providing quality emergency care. The combination of operational and process improvement will assist health care organizations in maintaining high-quality care. The past 2 decades have seen ED crowding recognized as a national health care concern that has been increasingly connected to poor patient outcomes. 1,2 A national trend since 1995 has seen ED visits increase nationally by 20% with a simultaneous decrease in operational emergency departments by 9%. This inverse relationship has equated to a 31.4% increase in visits per emergency department each year. 3 This volume increase, coupled with the federal mandate outlined by the

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Crystal Hayden is Chief Nursing Officer, Onslow Memorial Hospital, Jacksonville, NC. Penney Burlingame is Senior Vice President Nursing and Clinical Services, Onslow Memorial Hospital, Jacksonville, NC. Holly Thompson is Assistant Medical Director, Emergency Department, Onslow Memorial Hospital, Jacksonville, NC. Valerie K. Sabol is Associate Professor, Specialty Director, Acute Care Nurse Practitioner Master’s Program, Duke University School of Nursing, Durham, NC. For correspondence, write: Crystal Hayden, DNP, MSN, RN, FACHE, Onslow Memorial Hospital, 317 Western Blvd Jacksonville, NC 28540; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.09.011



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Emergency Medical Treatment & Labor Act of 1985 to provide a medical screening examination (MSE) to all patients regardless of ability to pay, has caused a crisis in emergency departments across the nation. The literature reflects that one method to impact patient safety, quality, and the patient experience is to provide an MSE in the triage setting by qualified individuals. 4 This will have an impact on the number of patients who leave the emergency department without seeing a provider because of unacceptable wait times. Currently, throughout the country, up to 3% of patients will leave an emergency department without seeing a provider. 6 This seemingly small number represents thousands of patients who leave emergency departments without seeing a provider or receiving care. The volume increase experienced across the country is a complicated and multifaceted phenomenon. Health care reform, economic hardships, lack of primary care, and many other factors are contributors to the complex problem of ED overcrowding and inefficient patient flow. Workforce shortages of emergency medicine physicians coupled with poor access to primary care dictate the need for hospitals to consider inserting an APP, early into the patient experience, as a potential solution to providing quality emergency care. The use of APPs in the ED setting has expanded over the past 10 years. Between 1997 and 2006, the proportion of ED patients seen by an APP has increased from 5.5% to 12.7%. 5 The use of APPs is beneficial because they are less costly than physicians, provide care in collaboration with a physician, and are widely accepted by patients. 6 Studies reflect that quality of care is impacted during crowding, which results in treatment delays and decreased patient satisfaction. 1 To fully understand the implications of ED crowding, additional investigation into quality indicators and standardized metrics may help guide the development of efficient systems to deliver high-quality care and decrease LWBS rates, length of stay (LOS), and door-to-provider wait times. These measures may be used to frame ED quality and thus be used as standardized

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indicators measuring patient satisfaction, patient retention, and patient perception of quality; coupled with other efficiency strategies, placing an APP early in the patient experience may significantly impact these quality metrics for ED operational efficiency and patient satisfaction. 7 In addition to these variables, consideration must be given to elopement rates and how they are affected by front-end operation strategies. The elopement rate is the complement to LWBS in that it is a measure of patients who leave after being seen by a provider but before treatment and disposition are complete. It is expected that the elopement rates may increase if other throughput initiatives do not address back-end ED flow. Using reliable strategies with a focus on quality improvement (QI) and the patient experience will allow the emergency departments across the nation to meet the increased utilization demand given the fewer operational emergency departments nationally. 8 Local Problem

The emergency department of a small, 162-bed community hospital in eastern North Carolina sees 63,000 visits per fiscal year, with an average LWBS rate of 5%, which is an increase from its average of 3.3% in 2007. This emergency department uses the Emergency Severity Index (ESI) triage system. The goal of ESI implementation is to accurately capture patient acuity and optimize patient safety. The category 3 ESI patient population currently accounts for 80% to 86% of the LWBS population. This sample of patients is recognized as a moderate- to high-risk population that would benefit from a front-end screening and examination. The benefit of having a primary care physician is significantly diminished by the barriers to access that care, which often leads to using the emergency department as an alternative source of medical care. Literature supports the belief that inconvenient primary care scheduling or the lack of primary care providers has been a factor in the ED volume increase, 9 with the argument for increased funding for primary care access on the premise that it is less expensive to see a primary care physician than incur an ED visit. Although most Americans report having a usual source of medical care, they also report significant barriers to timely access to primary care. 10 The eastern North Carolina county that is the subject of this article also has a lack of primary care physicians. The facility’s strategic plan, authored in 2011, includes the need for primary care physicians, medical and surgical specialists, and psychiatrists. Currently, the county is experiencing a significant deficit (24.6 full-time equivalents) in adult

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primary care. Given the projected population growth, aging, and a decrease in physician supply because of retirement, the deficit is projected to increase to 38.3 full-time equivalents by 2016.

Intended Improvement

The magnitude of improving front-end operations and reducing the LWBS rate to 2%, the national benchmark, could result in an average additional 168.4 visits to the emergency department per month, or 2,020.8 visits per year. To fully appreciate the financial and operational impact of these additional visits, it is important to note that the average admission percentage of ED patients is 10.2% per month, or 206 additional admissions per year. Each additional inpatient admission would result in approximately $5,865, and each additional ED visit would generate approximately $255 in contribution margin per case, for total recouped reimbursements of a minimum of $1,671,000 per year.

Ethical Issues

Ethical issues as related to the innovation were considered, such as patient privacy, protection of well-being, and conflict of interest. Patient well-being was discussed at length among the members of the project team. In addition, relationship enhancement and co-ownership were addressed. The physicians saw this clinical QI project as largely “external” to their practice, although they were concerned about “excessive” testing and were eager to use treatment protocols for the APP in the form of standing orders. Regulatory compliance was also a consideration for this clinical QI project because new regulatory standards will require continued attention to patient flow. The new Centers for Medicare and Medicaid Services–required ED metrics for 2012 include several for both outpatient populations and patients admitted from the emergency department. 11 The Joint Commission has released emergency department–specific standards such as LD.04.03.11, which states that “the hospital manages the flow of patients throughout the hospital.” The supporting elements of performance include measuring and setting goals for the components of patient flow, establishing methods to mitigate and manage boarding of ED patients (boarding is defined as ≥ 4 hours), and developing a process for measurement results to be reported to leaders.

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TABLE 1

ED visit summary Descriptor

Gender Female Male Emergency Severity Index level 1 2 3 4 5 No. of codes/No. of trauma patients Age b2 y 2–17 y 18–65 y N 65 y

Before project implementation (n = 11,463)

After project implementation (n = 11,480)

6,824 (59.53%) 4,639 (40.47%)

6,928 (60.35%) 4,552 (39.65%)

37 (0.32%) 1,280 (11.16%) 7,365 (64.25%) 2,562 (22.35%) 211 (1.84%) 40/34

16 (0.13%) 1,201 (10.46%) 6,283 (54.73%) 2,563 (22.32%) 219 (1.91%) 16/42

593 (5.17%) 1,456 (12.70%) 8,373 (73.04%) 1,041 (9.08%)

594 (5.17%) 1,650 (14.37%) 7,079 (61.66%) 948 (8.25%)

Inpatient Capacity

In 2011, the facility had a 59.4% occupancy rate of the 134 adult, acute care medical surgical beds. With a reduction in the LWBS rate to 2%, an increase in inpatient admissions by 206 additional admissions per year, or 17.2 admissions per month, could conservatively be estimated. With an average LOS of 4 days, this would yield 68.8 additional patient days per month, or 2.3 additional patients per day. Capacity exists to absorb the additional admissions without increasing staff or space.

ED Capacity

For the 2011 calendar year, the facility saw 67,358 ED visits, with an average of 184.5 visits per day. Current staffing allows for a physician and APP capacity of 195 ED visits per day. Reducing the LWBS rate to 2% will add an additional 168.4 visits per month, or 5.6 additional patients per day. This will increase the daily average to 190.1 patients per day, or 97.5% of the current provider occupancy rate. Should additional volume increases occur, additional provider hours would need to be considered. On the basis of the calculation of bed space capacity, the average ED visit (admission and discharge combined) totals 4 hours. Given 24 hours per day, each bed will accommodate 6 visits and yield enough space for 246



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patients per day. Capacity exists to absorb the additional visits without increasing staff or space.

Methods

The clinical QI project focused on placing an APP into the triage process to evaluate all adult and pediatric triage level 3 ESI patients during the emergency department’s busiest hours: from 10 AM to 10 PM. Currently, the facility uses a pivot nurse in a contemporary triage role. The pivot registered nurse is located in the lobby and interacts with all patients on arrival. Patient information is collected using basic questions around chief complaint, medical history, allergies, and pain. After this brief triage, if said criteria are met, the pivot nurse assigns an ESI level of 3. These patients receive an MSE by the APP and initiation of orders. The project sample consisted of 22,942 ED visits, summarized in Table 1. As reflected in Table 1, the percent of visits between the pre- and post-project samples remained constant for gender. The age and ESI descriptors remained constant between the pre- and post-project samples given their relative volumes to one another. The number of codes (cardiopulmonary arrests) decreased between groups. There were no activity trends or contributing factors noted for this variation. The clinical QI project conducted mean comparison tests to determine statistical significance of the intervention

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(P b .05). All outcome variables were continuous, and thus statistical analyses involved comparing means or mean ranks between pre- and post-project groups on each outcome variable. Preliminary analysis involved tests to examine normality of the outcome variables of LWBS rate, doorto-provider time (in minutes), and LOS (in minutes). Shapiro-Wilk tests showed that the LWBS rate was nonnormally distributed; therefore the nonparametric equivalent of the t test, the Mann–Whitney U test, was conducted. Door-to-provider time and LOS rate were normally distributed; therefore analysis of variance tests were used to compare pre- and post-project data on those outcomes. Data were analyzed with SPSS software, version 21.0 (IBM, Armonk, NY).

realized; the elopement rates were 0.06% (July 2011) and 0.49% (August 2011) before project implementation compared with 2.3% (September 2011) and 1.4% (October 2011) after implementation. The financial impact of reducing the LWBS rate was not realized during this improvement project, nor was a significant improvement in patient satisfaction realized. During the pre-project months of July and August, patient satisfaction (as measured by the national company Professional Research Consultants, Omaha, NE) reflected an average excellent score of 43.5% (n = 396) as compared with 41.9% (n = 381) during September and October. Patient satisfaction decreased, though not at a statistically significant level. The financial impact was not realized because of the lack of reduction in the LWBS rate.

Results

ED volume statistics for the study period include 22,937 ED visits, with a pre-project volume of 11,463 during July and August 2011 and 11,480 visits during the post-project time of September and October 2011. Analysis showed no aggregate statistical differences in the pre- and post-project groups for service line admissions. The provider-in-triage process was open a median of 12 hours per day. The preproject LWBS population was 624 patients, or 5.4% of the total patient population. The post-project LWBS population was 675 patients, or 5.8% of the total patient population. These post-intervention results compare unfavorably with the most recent national average of 3.1%. 12 LOS analysis showed an average LOS of 292.05 minutes in the pre-project period and 275.4 minutes in the post-project months. Door-to-provider analysis reflects an improvement from 71.1 minutes before the project to 47.9 minutes after the project. For LWBS rate and LOS, we found no statistically significant difference between pre-project and post-project groups (P = .38 and P = .07, respectively), although LOS appears to be trending toward significance. The door-toprovider time was significantly less in the post-project months (mean, 47.79 min) than in the pre-project months (mean, 71.07 min) (F1,121 = 41.63, P b .001) and suggests that the implementation of an APP in triage has a statistically significant and clinically relevant impact on the door-toprovider time for patients and a clinically relevant (though not statistically significant) impact on LOS. Although the door-to-provider time decreased, the LWBS rate did not decrease as expected, and because patients were seeing a provider more quickly, the elopement rate was expected to increase as patients decided to leave before treatment was complete but after seeing the APP in triage. This was indeed

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Discussion

Although the improvement in door-to-provider time from this QI project is encouraging, the performance of the other metrics was disappointing. Evidence overwhelmingly supports the use of a provider in triage to increase front-end efficiencies of the emergency department; however, some discrepancy remains as to whether this should be a physician or APP. 13–16 Although the QI project showed no change in the LWBS rate, patient satisfaction, or financial recoupment, the project did realize a statistically significant reduction in door-to-provider time, which is supported by previous studies, 13–15 and a favorable trend in LOS. Overall, the LWBS rate and patient satisfaction, though not significantly impacted, should be further explored for the influence of other factors not considered in the original clinical QI project. Several additional points that should be discussed include issues with bed utilization, the pivot nurse process, and the length of time required for the APP to complete triage and the MSE. With these issues addressed, the program would, most likely, experience more success. In addition, discussion occurred about using both physicians and APPs in the triage role. The focus would then become a “provider in triage” with the physicians and APPs sharing the responsibility for staffing triage. This support will be paramount to the success of the provider in triage facilitating order initiation and patient flow. The positive impact on the door-to-provider time is a positive catalyst, showing that this concept will work. In actively addressing the barriers to its initial success, the provider-in-triage process, with dedicated resources, may decrease an organization’s LWBS rate. The patient satisfaction and financial metrics were not impacted because of the inability to positively affect the LWBS or LOS values. When we consider the reasons for

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TABLE 2

Post-project findings Metric

Fiscal year 2012 objective

January-November 2012

Last 90 days (September-November 2012)

Last 30 days (November 2012)

Leave without being seen rate Door-to-provider time Length of stay

≤ 2% ≤ 45 min ≤ 240 min

3.06% 56.45 min 270.37 min

2.22% 50.51 min 263.48 min

1.70% 49.28 min 251.34 min

these results, patients may have initially been pleased with being seen quickly but then, without a significant reduction in LOS, became dissatisfied. Evidence shows that once the ED visit exceeds 240 minutes, there is an inverse relation between LOS and patient satisfaction. 17 In addition, patients who were initially seen and had treatment started and then later eloped would still receive a bill from the hospital for services rendered. Patients may believe that having to pay for incomplete treatment is not indicative of a quality service or environment, leading to poor satisfaction after the visit. Initially, consideration was given to abandoning the study because of lackluster results. However, the study was important because it allowed system issues to be recognized and highlighted so that they could be addressed. Though not statistically significant, the LOS reduction was clinically important and should be considered a positive finding as well (Table 2).

Limitations

Because this study was performed at a single institution, generalizability is limited. Several days of understaffing may have impacted results. Another element limiting the scope of this clinical QI project is related to physician buy-in and support. Lukewarm support was encountered initially, but support did improve over the course of the QI project. Although quality indicators showed minimal, if any, improvement, system barriers and limitations to quality patient care were identified. Post-project initiatives have since been implemented to improve system-related operations and are projected to be sustainable over the long-term.

patient experience are critical elements in providing a safe and therapeutic environment in which patients receive care. Plans to build on the limited success of this project include developing and implementing expanded and standardized treatment protocols, hardwiring staff and resource allocation, and sharing the provider-in-triage responsibility among both APPs and physicians. In addition, an ED steering committee made up of departmental and organizational leadership will be developed. This committee will meet monthly and review quality and operational metrics, discuss barriers to flow and patient care, and address ideas for improvement. Understanding the inherent link among improved patient throughput, patient experience, and patient outcomes, it is imperative that the lessons learned from this project continue to be vetted for sustainability and that identified barriers are addressed to leverage additional improvements. In 2006 the Institute of Medicine called for improved operations management to support ED efficiencies and mitigate the effects of overcrowding. 18 For many emergency departments, this improvement lies in targeting strategies that improve ED throughput. Sufficient evidence exists to encourage the use of an APP in triage to decrease LWBS rates, LOSs, and door-to-provider wait times. By positively impacting these metrics, patient safety and health outcomes are improved, as is the overall patient experience, resulting in improved patient satisfaction. Our small community hospital continues to implement patient flow improvements based on findings from this clinical QI project.

REFERENCES Conclusion

With increasing pressures on emergency departments to reduce wait times and improve patient flow, it is imperative that accurate and consistent data be collected to monitor the flow of patients into the health care delivery system. Continuing to address flow barriers, patient safety, and the



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1. Johnson KD, Winkelman C. The effect of emergency department crowding on patient outcomes: a literature review. Adv Emerg Nurs J. 2011;33:39-54. 2. Hwang U, McCarthy ML, Aronsky D. Measures of crowding in the emergency department: a systematic review. Acad Emerg Med. 2011;18:527-38. 3. Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data. 2007;386:1-32.

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4. Rubino L, Stahl L, Chan M. Innovative approach to the aims for improvement: emergency department patient throughput in an impacted urban setting. J Ambul Care Manage. 2007;30:327-37.

12. Hing E, Bhuiya F. National Hospital Ambulatory Medical Care Survey: 2009 Wait Time for Treatment in Hospital Emergency Departments. Atlanta, GA: National Center for Health Statistics; 2012.

5. Welch S, Savitz L. Exploring strategies to improve emergency department intake. J Emerg Med. 2011;43:149-58.

13. Choi YF, Wong TW, Lau CC. Triage rapid initial assessment by doctor (TRIAD) improves waiting time and processing time of the emergency department. Emerg Med J. 2006;23:262-5.

6. Menchine MD, Wiechmann W, Rudkin S. Trends in midlevel provider utilization in emergency departments from 1997 to 2006. Acad Emerg Med. 2009;16:963-9. 7. Sanchez M, Smally AJ, Grant RJ, Jacobs LM. Effects of a fast-track area on emergency department performance. J Emerg Med. 2006;31:117-20.

14. Han JH, France DJ, Levin SR, Jones ID, Storrow AB, Aronsky D. The effect of physician triage on emergency department length of stay. J Emerg Med. 2010;39:227-33.

8. Welch S, Dalto J. Improving door-to-physician times in 2 community hospital emergency departments. Am J Med Qual. 2011;26:138-44.

15. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial. Acad Emerg Med. 2007;14:702-8.

9. Tranquada K, Denninghoff K, King M, Davis S, Rosen P. Emergency department workload increase: dependence on primary care? J Emerg Med. 2010;38:279-85.

16. Rowe BH, Xiaoyan G, Villa-Roel C. The role of triage liaison physicians on mitigating overcrowding in emergency departments: a systematic review. Acad Emerg Med. 2011;18:111-20.

10. Rust G, Ye J, Baltrus P, Daniels E, Adesunloye B, Fryer G. Practical barriers to timely primary care access: impact on adult use of emergency department services. Arch Intern Med. 2008;168:1705-10.

17. Boudreaux E, Friedman J, Chansky M, Baumann B. Emergency department patient satisfaction: examining the role of acuity. Acad Emerg Med. 2004;11:162-8.

11. Centers for Medicare and Medicaid Services. Specifications Manual for National Hospital Inpatient Quality Measures. Version 3.1a. Baltimore, MD: The Joint Commission; 2010.

18. White BA, Brown DF, Sinclair J. Supplemented Triage and Rapid Treatment (START) improves performance measures in the emergency department. J Emerg Med. 2010;42:322-8.

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Improving patient flow in the emergency department by placing a family nurse practitioner in triage: a quality-improvement project.

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