Having a provider in triage (PIT) has transformed our ED in a way I didn't anticipate. ED volumes are falling everywhere, but ours is climbing. EDs are experiencing nursing shortages, boarding admissions, and behavioral health patients, but we have record volumes that are rising, and we consistently have record low left-without-being-seen rates.
I work for an independent democratic group that staffs a small rural ED of 14 beds in the mountains of North Carolina. I had an unforgettable case the first month I arrived, bright-eyed and straight out of residency. My patient was in her 80s, and had suffered an acute ischemic stroke, leaving her paralyzed on one side. She was within interventional timeframes when she arrived at our ED. But by the time I saw her hours later, she was untreatable. She had sat in our waiting room far too long. She died a few days later. I was so disturbed by this encounter that I wrote down all the details and have kept them all these years.
Fast forward five years. It was winter, and we were boarding admissions, as always. Every shift, I would helplessly watch the number of patients in the waiting room grow and grow with no end in sight, leaving me dejected and deflated. As an independent group entirely reliant on volume for our paychecks, we were literally watching money walk out the door with every LWBS, not to mention the problem of inefficient and poor-quality patient care.
Necessity is the mother of invention, as they say. My partner confided that he was seeing patients in a security office in the lobby. I started doing the same thing whenever the security office wasn't occupied. A few months later, one of our hospital's vice presidents mentioned the idea of a provider in triage, and I jumped at it. One of our sister hospitals of similar size and volume had dropped their LWBS by astronomic proportions, and was seeing their volumes climb. We decided to go see what they were doing.
They had started a PIT, for one thing. There were other initiatives too, but that intrigued me the most. We repurposed the registration manager's office into a PIT room. We didn't schedule anyone to work in it at first. We would just head out there when the back wasn't moving because of boarders. And it started working. Over a few months, we had seen several hundred patients out there—in our spare time. Our LWBS rate was dropping.
We decided to experiment with staffing it with some APPs just on our busiest days: Sunday, Monday, and Tuesday. It was quickly obvious that something was working. We started trying to staff it as often as possible with PRN staff, about three to five days a week. Eventually, we went to the hospital and asked them to partner with us to staff the PIT seven days a week. It was going to cost our group a lot of upfront capital to hire full-time staff, and we still were not 100 percent sure the investment would pay off. After lengthy negotiations, they agreed.
The numbers speak for themselves: Our ED volume in 2016 averaged 70 patients a day, and our LWBS rate was 6.5 percent. Two years later, our ED volume averaged 81 patients a day, and our LWBS was less than two percent. We started running PIT seven days a week in September. Things are changing that fast.
We have consistently had days where volume exceeded 100 patients, still with record low LWBS rates: one to three percent over the past two months. We saw 114 patients on Super Bowl Sunday, and only had two patients leave without being seen. We still have nursing shortages, and still board admissions and behavioral health patients. Just last week my partner said they were boarding 15 admissions in our 14-bed ED with average lengths of stay of more than 10 hours. Yet we saw more than 80 patients that day!
A week ago, on a Sunday, we saw 100 patients, boarded 11 admissions with more than six-hour lengths of stay, and had no patients leave without being seen. Impossible numbers. I would have laughed if someone had told me those numbers two years ago.
Looking at old data and logs, I was intrigued to learn that back when I had that tragic case, our volume was only 75 patients a day, and our LWBS rate was 4.7 percent. In a sense that patient years ago paid the ultimate price for our inefficiency, but her death wasn't in vain. I'm committed to never allowing that to happen again in my ED, and I'm hoping that our experience will motivate you so that it won't happen (again) in your ED either.
I've met several jaded emergency physicians who said they tried a provider in triage, but it didn't last. Some argued that solving the boarding problem is an administration problem, not an ED problem. But I've come to see the hospital as an organism, and the ED is its most sensitive part. Everything—and I mean, everything—that happens in the hospital will affect the ED. An ICU nurse calls in sick, so we start holding ICU patients in the ED. Elective OR cases directly affect ED boarding every single business day, as many of us know. (I've started to tackle that, but as expected, buy-in has been a big obstacle.)
Like all emergency physicians, I'm trained to identify a problem and find a solution, to improvise, if necessary. That's essentially what PIT is: an improvised solution. It does not fix the backlog of boarders, but it keeps the patient flow moving. Being part of a small, private independent group has allowed me to continue a long-lasting relationship with our administration built on the foundation of our prior medical director who was here for nearly 18 years.
I'm happy to report that despite starting many recent shifts with eight to 10 boarders, I don't lose heart. I know everyone will be seen. Most importantly, I know we will not have someone sit in our waiting room with a potentially life-threatening event until she is out of an interventional window again.
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Dr. Parrishis the director of UNC Caldwell's Emergency Department and Urgent Cares and a partner with Mountain Emergency Physicians, PA.Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.