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Boost capacity, slash LWBS rate with POD triage system
Approach frees up beds, expedites patient flow
With volume on the increase and a leave-without-being-seen (LWBS) rate already at 5%, ED administrators at Methodist Hospital of Sacramento in Sacramento, CA, knew they needed to come up with a way to get patients moved through the ED more expeditiously at least until a planned expansion of the ED took place, but in early 2008, that was still more than a year away.
"We were in an ED that was seeing close to 48,000 patients each year, and we were functioning out of a nine-bed ED with six [additional] fast-track beds at the time, and only one triage nurse," explains Tris Rieland, MD, medical director of the ED at Methodist Hospital. "When you have ten people signing in [to the ED to be treated] and there is only one person who they are being funneled through, that is going to create a bottleneck."
Concluding that more triage capacity was needed, administrators decided to take the six fast-track beds offline and turn them into triage beds, says Rieland, noting that under this "POD triage" approach, patients would be brought to a bed for triage soon after they walked in the door. Further, while there was no change made to physician staffing, there were some adjustments made on the nursing side.
"We increased staffing with a triage nurse and added a task nurse who managed the flow of the triage pod," explains Cindy Myas, RN, director of the ED at Methodist Hospital.
Despite such adjustments, Rieland admits he was skeptical that turning over six of his 15 beds to triage would be helpful, but the approach worked remarkably well.
"Within a month it made our waiting room a ghost town in the sense that no one was really ever waiting to be seen," says Rieland. The LWBS rate dropped below 2%, and the door-to-doc time was trimmed from 50 minutes to 30 minutes, adds Myas.
Quick decisions keep patients moving
There is more to the "POD triage" model than just adding triage beds. The system governing how the beds are used keeps patients moving through the system, explains Rieland. For example, when patients are brought back to a triage bed, the clock starts ticking down a 15-minute period during which one of three decisions must be made by the treating providers: They can either discharge the patient with a prescription or some other recommended course of treatment; they can order lab tests or X-rays and, then, if the patient is stable, send him back out to the waiting room while the tests are completed; or if a patient is sick and needs to be placed on a cardiac monitor or hooked up to IV fluids, he can be sent to a bed in the main ED.
Transitioning to such a system requires a "cultural shift in thinking" from both the physicians and the nurses, adds Rieland. In particular, clinicians have to get used to the idea that not all patients have to be in beds when they are assessed and treated. "We call it keeping them vertical for most of their ED stay," he says.
Initially, there was some pushback to the idea from both physicians and nurses. One of the stumbling blocks had to do with the question of what should be done with patients who are placed on IV fluids. "The group came to the consensus that if patients need IV medications, we are not going to send them back out to the waiting room," says Rieland. "We will give them oral medicines and maybe an intramuscular shot to make them comfortable, but we will not put an IV in and send them back out to the waiting room," he says.
Such issues can be resolved, but they require a collaborative approach that invites input and discussion, stresses Rieland. "When we designed this we had meetings for up to two months prior to the time when we first went through the whole process," he says. "We got nurses, mid-levels, and physicians involved in the process."
Myas agrees that it is important to get as many staff involved in the planning stages as possible, but she stresses that you also need to consider your geographic layout when designing any new system changes. In fact, geography became an issue when the hospital opened a new waiting room in January of this year as part of a four-phase expansion of the ED.
"Because of the way the waiting room is currently situated in the department, we don't have six beds in close enough proximity to walk the patients straight back [for triage]," says Rieland. "It doesn't quite fit our flow model."
As result, the ED is temporarily switching back to its old triage model until it regains access to six nearby beds in about six months. Then it will transition back to the POD triage system, says Rieland.
Get staff involved with decision-making
Approaching change in an inclusive way can not only create ownership of the new process, it also nurtures camaraderie and a team mentality, says Tris Rieland, MD, medical director of the ED at Methodist Hospital of Sacramento in Sacramento, CA.
This way, when nurses or physicians complain about some aspect of the new approach, these gripes get dismissed pretty quickly by the rest of the staff if the complainants haven't participated in the process, he says.
"If they've got a problem, it is okay, but they come to realize that they need to show up at a meeting to get it fixed rather than voicing it on the floor."