Tuesday, July 24, 2012

The Value of a Nurse Practitioner, Physician Assistant or Physician in Triage - Is placing a provider in triage cost effective?

The experience I’ve had in a 65,000 visit ED has been mostly positive.
  1. Door to provider is 35 minutes of less on average
  2. Room to provider is 15 minutes or less
  3. AWOLS are 2% or less even when total volume rises to 200 pts/day
  4. When the volume climbs above 200 pts/day--corresponding to admissions of about (60/day)--the benefits of physician triage are less consistent.  Why?  Complications arise; these result from a variety of factors augmented by the increased load, and include: an increased number of patients being held in the ED, overcrowding-stimulated variances in patient mode of entry, and--most importantly--a relative decrease in available nursing and ancillary staff.

Role of triage provider:
  1. Initiate testing with rapid diagnosis and disposition in mind.  The goal to keep in mind:  enable the interior ED provider to make a 1 pass visit for a final admit or discharge disposition.
  2. Be alert for high risk, subtly ill, patients (Level 3) Standard nursing triage classification has some shortcomings here. Moreover, in times of higher triage volume, periodically scan the waiting room and the queue for such patients that might be later in line, or overlooked.
  3. See minor cases and discharge without tying up beds. (e.g.  med refills, toothaches) (Level 1)
  4. Try to distribute patients with an “eye on flow.” If possible and practical, to all areas evenly (Level 2, 3).
  5. When possible visit patients that bypassed triage(brought by rescue or walk-in) if free and sufficiently staffed. Especially in times when “the back” is swamped, but triage is not, the triage provider may see these patients, initiating care and diagnostic testing.  If the provider is able to safely leave triage, go to the back, and see these new un-triaged patients, the care process can be accelerated dramatically.
  6. Preorder on patients that came by rescue or were sent directly back without triage that the other provider has not seen.
  7. Initiate minimal treatments like Zofran, ASA, and Tylenol on patients that will be entering the ED for further care (Level 2,3)

Is it cost effective?

We think so. Indeed, we have found that our treated volume has increased 10-20% using the same staffing model plus physician triage.

Difficulties to anticipate:
  • It’s not for everyone. That is, such a plan is not for every emergency department, and likewise not for every provider, either.  It is advantageous to experiment first, before committing resources, to work out “bugs” and get a feel for how this will work in your particular ED, and with your individual physicians.
  • A provider with rapid multitasking skills is needed.
  • Shoot for an upper level of pre-order accuracy…say  95%.  This can be determined by the number of tests/treatments were added on a given patient inside the ED.  If none are ever added (100% accuracy) then a case can be made for over-ordering in triage.  If too many are additionally added all the time –increasing patient stay--(say an additional 50%) then more care and diagnostics need to be started in triage. 

Patient acceptance:

“Mikey likes it.” That is, when the process and procedures are explained to patients and families by the staff, they are generally very accepting


When your administration asks you to see every patient in 30 minutes or less, this is the easiest first step. Of course, it does not solve all problems. To fully control LOS is entirely another animal altogether.  With physician triage, therefore, you make some significant and noteworthy progress, but it may only take a small bite out of your overall LOS statistics.

1 comment:

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