NACHRI & N.A.C.H. 2009 Creating Connections Conference

QI - Building The Clockwork Pediatric Emergency Department

Timothy Lee, MD, Pediatric Emergency Medicine Physician
Nicole Johnson, Nurse Manager
Children's Hospital Medical Center of Akron, Akron, OH

Learning objectives:   After viewing this poster attendees should be able to:

1. To describe how toggled rapid triage practices impact door-to-doctor time.
2. To describe how bedside registration impacts door-to-doctor time.
3. To describe door-to-doctor time impact on ED operational measures.

Introduction/background:
Door-to-doctor time, that interval between when a patient arrives to the emergency department (ED)and when they are seen by a physician, impacts several operational measures. Practices to reduce door-to-doctor time should favorably impact patient satisfaction , overall length of stay, ED crowding and frequency of patients leaving the ED before evaluation. The aim of this presentation is to describe the implementation of toggled rapid triage practice and bedside registration in the ED and the impact on key operational measures.

Initiative or project description:
With internal process improvement expertise and affiliation with a healthcare consulting group, our ED leadership identified opportunities to implement best practice initiatives with the overarching goal to improve patient throughput. Our working group involved several ancillary departments in our hospital and conducted weekly meetings over a six month planning phase. Two initiatives described in this presentation impact the door-to -doctor time interval. The first initiative, toggled rapid triage, discriminates when ED capacity allows for rapid triage practice at the patient entry-point. Traffic stoplights in the ED waiting room and main work station inform patients and staff of ED capacity. A green light is displayed when there is room to take patients immediately to an exam room, while a red light indicates that the ED is at capacity and a wait to see a doctor might be expected. Comprehensive triage is performed in the patient's room instead of the ED entry point during "green light." Pre-emptive testing is utilized when the ED is at capacity. The second initiative, bedside registration, decreases door-to-doctor time by placing the patient registration process in parallel with other ED visit-related activities instead of in series.

Results/Outcomes:
Toggled rapid triage and bedside registration practices have been in place for one month at the time of this submission. When compared to the same time one year ago, there has been a 25 percent (34 to 22 minutes) decrease in door-to-doctor time interval and a 12 percent decrease in overall length of stay (112 to 99 minutes). At the time of presenting our results, we expect to have more comparison measures such as more complete throughput data, patient satisfaction measures and incidence of patients left before evaluation.

Future of initiative:
We will continue to collect data on the mentioned initiatives and target other nodes in the patient throughput process such as additional pre-emptive test guidelines and diagnosis-driven protocols, the throughput of patients bound for hospital admission, staff communication and individual physician practice.

Lessons learned:
This presentation will describe efficacy of toggled rapid triage and bedside registration practices on operational measures in the ED. This description will also include lessons learned with regard to implementing the sea-change initiatives mentioned above, for example, the best approach to organization and engagement of ancillary hospital departments. We have found that consistent practice of process improvement methodology and proactive problem solving are essential to initiating and maintaining change.