Fairview Ridges Emergency Department realized that to provideexceptional care, it must leverage opportunities to streamline the processes of arrival and triage. In 2011, the average patient arrival to physician examination time, now known colloquially as Door-to-Doc, was 54 minutes. Process innovations including open rooming, ‘Pull-‘til-Full’, double RN triage during peak hours, andmultidisciplinary bedsidetriage brought that number to 37.2 minutes for 2012.As the processes gained root, staff ownership ofa new standard emerged.Continued dedicationof staff and physicians together toadjust, hone,and perfect these processes throughout 2013 broughtthe average to 17.4 minutes.
Scope, Originality and Implementation
Fairview Ridges Hospital has long been proud of the excellent care it providesto the South Metro area. Thisspirit of excellence propelled the Emergency Department to develop a series of innovative measures designed to improve its system of patient arrival and triage. With the firm belief that patient care, safety and satisfaction are optimized when definitive care is expedited, the focus became improving the time between patient arrival and physician contact time (Door-to-Doc time). Work began with a Vision Team that researched best practice, visited other unassociated sites, and creatively applied itsfindings to ultimately overhaul the department’s existing process.What ensued was an iterative change process that called for the proactive best from every member of the department.
The first initiative, an open rooming system for physicians, removed the boundaries of assigned rooms, allowing doctors to accept patients as their work flow allowed. RN’s and support staff continued to work in an assigned pod system. The new process, which promoted teamwork and accountability between physicians, also prevented vacant rooms from being heldwhen physicianswere changing shift or attending critical cases.
This new flexibility led to the concept of ‘Pull-til-Full,’ wherein patientsare pulled directly back for triage at the bedside, eliminating the stop at a triage station when rooms are available. Vocera communication devices, acquired for all staff, announce the arrival of untriaged patients so that appropriate caregivers arerouted to the room. This allows initial care and triage data gathering tooccur simultaneously. Further enhancement enlisted the ED physicians who now, as often as possible, join the triage team. It has become routine practicefor patientsto be taken directly to a room where one nurse documents arrival information, anotherdraws blood and starts an IV, a technician obtains vital signs and possibly an EKG, all while a physician begins the exam. Patients appreciate telling their story only once. Vital information is gathered quickly. Definitive care is initiated rapidly. The addition of a second RN at triage during peak hours has allowed bedside triage to continue during busy times of the day.
Effectiveness in Achieving Purpose
A dramatic decrease in Door-to-Doc times immediately followed the work’s inception. The continued efforts of staff to own, adapt, and improve the practices initiated by the Vision Team brought further improvement. Throughout this work, average Door-to-Doc times dropped from 54 minutes in 2011 to 37.2 minutes in 2012. For 2013 this average further dropped to 17.4 minutes, which is well below the national benchmark.
The work’s effectiveness could be clearly linked to two lagging indicators. As Door-to-Doc times decreased, the department’s national overall patient satisfaction scores for similar size hospitalsincreased from the sixty-eighth percentile in 2011 to the ninety-second percentile in 2013. Additionally, the number of patients who Left Without Being Seen decreased from 1.44% to 0.55%.
Applicability
This innovative process, offering rapid improvements and patient outcomes, is easily duplicated in any facility. As a result, a larger area hospital is currently implementing this process.