Triage: Fixing the Front End Emergency Nursing Seminar The 2 nd Mediterranean Emergency Medicine Congress David Eitel MD MBA [email protected]

Triage: Fixing the Front EndTriage: Fixing the Front End

Emergency Nursing SeminarEmergency Nursing SeminarThe 2The 2ndnd Mediterranean Emergency Medicine Mediterranean Emergency Medicine

CongressCongress

David Eitel MD [email protected]

In Memory Of:In Memory Of:Richard Wuerz MD Richard Wuerz MD

Associate Clinical DirectorAssociate Clinical Director

Department of Emergency MedicineDepartment of Emergency Medicine

Brigham and Women’s Hospital Brigham and Women’s Hospital

Harvard Medical School Harvard Medical School

Richard C. Wuerz, MD1960-2000

On Behalf Of The ESI Triage Research Team:On Behalf Of The ESI Triage Research Team: Nicki GilboyNicki Gilboy

Alex RosenauAlex Rosenau

Debbie TraversDebbie Travers

Tom Stair (the database guru)Tom Stair (the database guru)

Melissa SchlenkerMelissa Schlenker

Dave EitelDave Eitel

Rich WuerzRich Wuerz

Thank you for the invitation!Thank you for the invitation!

Emergency Medicine ExplainedEmergency Medicine Explained

1 patient arrives patient arrives 2 stuff happens stuff happens 3 patient leavespatient leaves

U.S. Emergency Department VisitsU.S. Emergency Department Visitswww.acep.orgwww.acep.org

The Good News!The Good News!

0

10

20

30

40

50

60

70

80

90

100

1975 1980 1985 1990 1995

Mil

lion

s of

vis

its

http://www.acep.org/

The Bad News…The Bad News…U.S. GAO, 1993U.S. GAO, 1993

17%

40%

43%

urgent

emergent

non-urgent

““The Emergency Department The Emergency Department Problem”Problem”

Silver, Manegold, Silver, Manegold, JAMA JAMA Oct 24, Oct 24, 19661966

ED visits rose 175% from 1955-1965ED visits rose 175% from 1955-1965 42% ‘nonurgent’ problems42% ‘nonurgent’ problems Factors: Factors:

– Mobility (no primary doctor)Mobility (no primary doctor)– Difficulty finding a physician at night!Difficulty finding a physician at night!– Indigent populationsIndigent populations– 24/7 diagnostic facilities at hospital24/7 diagnostic facilities at hospital

“…“…the most costly care of all…”the most costly care of all…”– Marginal costs of minor emergencies = $25Marginal costs of minor emergencies = $25

Use of ED as source of primary careUse of ED as source of primary care– 43 M without health insurance43 M without health insurance– Insurance card does not equal accessInsurance card does not equal access

Definition of ‘emergency’Definition of ‘emergency’– Prudent layperson movementPrudent layperson movement

Health Care DebateHealth Care Debateand through the 1990’sand through the 1990’s

Definitions of ‘emergency’Definitions of ‘emergency’

life threatlife threat life or limb threatlife or limb threat results in hospital admission or operationresults in hospital admission or operation requires care within 2 hoursrequires care within 2 hours requires care within 24 hoursrequires care within 24 hours severe painsevere pain my lawyer sent me in to get checkedmy lawyer sent me in to get checked

The The REALREAL ED Problems ED Problems Cost Cost

– Perception that we ‘cost too much’ Perception that we ‘cost too much’ Quality\Satisfaction Quality\Satisfaction

– Variation in timeliness to careVariation in timeliness to care– Single biggest thing patients complain about is wait timeSingle biggest thing patients complain about is wait time

Now overcrowding: “access block” by AussiesNow overcrowding: “access block” by Aussies SafetySafety and nursing exodus and nursing exodus

What is triage? What is triage? Why do we do it? Why do we do it?

What does triage have to do with any of What does triage have to do with any of this anyway? this anyway?

Driver of My InterestDriver of My Interest

MBA Operations Management (95): Reengineering 101MBA Operations Management (95): Reengineering 101– Pick a businessPick a business that’s in trouble (The YH ED)that’s in trouble (The YH ED)– Identify it’s key business processes (?)Identify it’s key business processes (?)– If something is broken – FIX IT!If something is broken – FIX IT!

Every one did itEvery one did it – – but differently – even same laterbut differently – even same later ““Reengineering The ED – Fixing Triage”: Streaming,Reengineering The ED – Fixing Triage”: Streaming,

not just sortingnot just sorting Predictive management and modelingPredictive management and modeling

BWH Triage GuidelinesBWH Triage Guidelines before 4/99before 4/99

Emergent:Emergent: 1%1%– requires immediate evaluation & treatmentrequires immediate evaluation & treatment

Urgent:Urgent: 65%65%– can tolerate a period of time in the waiting room can tolerate a period of time in the waiting room

Non-urgent:Non-urgent: 35%35%– minor illness/injury that can be treated within six minor illness/injury that can be treated within six

hourshours

Emergency Nurses AssociationEmergency Nurses Association

Emergent/1Emergent/1:: – Life- or limb-threatening illness/injuryLife- or limb-threatening illness/injury

Urgent/2Urgent/2:: – Requires prompt care, but will not cause loss of life Requires prompt care, but will not cause loss of life

or limb if left untreated for several hoursor limb if left untreated for several hours Non-urgent/3Non-urgent/3::

– Time is not a critical factor; minor illness or injuryTime is not a critical factor; minor illness or injury

Triage Data Report YH ED 1997Triage Data Report YH ED 1997

22 % 22 % admitsadmits

18,029 18,029 visitsvisits

Jan-Apr Jan-Apr 9797

11 %11 %73 %73 %13,15013,150Level 3Level 3

51 %51 %25 %25 %4,5774,577Level 2Level 2

69 %69 %2 %2 %302302Level 1Level 1

ADMIT %ADMIT %%%VOLUMEVOLUMETRIAGETRIAGE

Inconsistency of TriageInconsistency of Triage Wuerz: Ann Emerg Med Oct 1998 Wuerz: Ann Emerg Med Oct 1998

87 nurses, two academic EDs 87 nurses, two academic EDs triaged 5 standardized patients scenariostriaged 5 standardized patients scenarios

– using their three-level scale scalesusing their three-level scale scales only 35% agreement beyond chanceonly 35% agreement beyond chance repeat triage of same cases: repeat triage of same cases:

– only 25% triaged the same both timesonly 25% triaged the same both times Conclusion: the instrument is too blunt! (no Conclusion: the instrument is too blunt! (no

instrument…)instrument…)

So what?

What Else Is Out There?What Else Is Out There?

Australian National Triage Australian National Triage Scale-1994Scale-1994

Canadian Triage and Canadian Triage and Acuity Scale-1996Acuity Scale-1996

Manchester Triage-1997Manchester Triage-1997

This patient can wait no longer thanThis patient can wait no longer than…to see …to see a physiciana physician

Australian & Canadian Triage

120 min120 min120 min120 min55

60 min60 min60 min60 min 44




CTASCTASNTS NTS Triage levelTriage level


A principal goal of Triage should be: A principal goal of Triage should be: To determine who should be seen first. To determine who should be seen first.

Right?Right?

If that is the If that is the onlyonly question asked question asked How longHow long do you thinkdo you think everyone everyone

should/could should/could waitwait??

A second major goal should be:A second major goal should be:Not just to “sort” but to “stream”Not just to “sort” but to “stream”

to get the right patient to the right to get the right patient to the right resources in the right place and at the resources in the right place and at the right time right time

The The Triage Game!Triage Game!

Observation: case scenarios - “they will need…” in agreement

There are There are big emergenciesbig emergencies, and there , and there are are little emergencieslittle emergencies

P.S. Experienced ED nurses are excellent at this! P.S. Experienced ED nurses are excellent at this! (especially those potential big emergencies…)(especially those potential big emergencies…)

If your little girl falls and cuts her If your little girl falls and cuts her forehead and needs stitches - forehead and needs stitches -

is that an emergency?is that an emergency?

It’s about resources!It’s about resources!

It’s not just about time:It’s not just about time:

Managing by Managing by flowflow, , Not capacity!Not capacity!

“The Goal”

To manage by To manage by flowflow, , have to first decide have to first decide

how to how to stream stream incoming patientsincoming patients

Not only who Not only who should be seen should be seen first, first,

But also, what does the patient need, in But also, what does the patient need, in terms of resources, to reach a terms of resources, to reach a disposition?disposition?

In ESI © triage two questions are asked:

The Bad News…The Bad News…U.S. GAO, 1993U.S. GAO, 1993

17%

40%

43%

urgent

emergent

non-urgent

The ESIThe ESI ©© V. 1V. 1 Triage Algorithm Triage Algorithm

Five levels, explicit definitions, complex tables Five levels, explicit definitions, complex tables In August 1998 In August 1998 Breakthrough! Flowchart-based Breakthrough! Flowchart-based

algorithm by Wuerz and Eitel: (Tufte)algorithm by Wuerz and Eitel: (Tufte) Vital signs ancillary (used to up-triage only, from 3 to Vital signs ancillary (used to up-triage only, from 3 to

2)2)– Heart rate>100Heart rate>100– Respiratory rate>20Respiratory rate>20– Oxygen sat<90%Oxygen sat<90%

Adults only (> age 14) Adults only (> age 14)

none one many

vital signs

1

2

5 4

3

yes

yes

no

no

yes

patient dying?

shouldn’t wait?

no

how many resources?

1yes

no

Intubated/pulseless/apneic?

Or

Unresponsive?

Step 2

Step 1:

2yes

no

High risk situation?

Or

Confused/lethargic/disoriented?

Or

Severe pain/distress?

Step 3

Step 2:

2

How many different resources does the patient

need?

Step 3&4:

none one many

Vitals criteria

5 43

yes

no

Vital Sign Criteria To Up-TriageVital Sign Criteria To Up-Triage

Would need ‘face validity’ of vital signsWould need ‘face validity’ of vital signs No clear consensus on ‘abnormal vitals’ No clear consensus on ‘abnormal vitals’ SIRS criteriaSIRS criteria

Reliability & ValidityReliability & Validity

ReliabilityReliability: reproducibility & repeatability of a : reproducibility & repeatability of a measurement tool (instrument)measurement tool (instrument)– Inter-rater Inter-rater agreementagreement– Test-retest Test-retest agreementagreement

ValidityValidity: Or So What?: Or So What?– Predictive validityPredictive validity– OutcomesOutcomes associated with each triage level associated with each triage level

Initial Adult-ESI Retrospective Initial Adult-ESI Retrospective Study: New Flow Chart Based Study: New Flow Chart Based

AlgorithmAlgorithm October-December October-December 19981998

““Reliability and validity of a new five-level triage Reliability and validity of a new five-level triage instrument”: Wuerz, Milne, Eitel, Travers, and instrument”: Wuerz, Milne, Eitel, Travers, and Gilboy: AEM Gilboy: AEM 20002000;7(3): 236-42;7(3): 236-42

Initial Adult-ESI StudyInitial Adult-ESI Study October-December 1998October-December 1998

Brigham and Mass General EDsBrigham and Mass General EDs New algorithm was first pilot tested among the New algorithm was first pilot tested among the

investigators with 20 written scenarios (k = .83 - .96)investigators with 20 written scenarios (k = .83 - .96) For 100 hours Oct - Dec 1998 simultaneous blinded For 100 hours Oct - Dec 1998 simultaneous blinded

triage of patients by a research nurse (n = 493)triage of patients by a research nurse (n = 493) All hours of the day sampled but by convenience All hours of the day sampled but by convenience


A second experimental ESI triage assignment was A second experimental ESI triage assignment was done retrospectively by a physician (RW) on 351 of done retrospectively by a physician (RW) on 351 of the written staff nurse’s triage note (k = .8)the written staff nurse’s triage note (k = .8)

There were 77% exact agreements, 22 one-level There were 77% exact agreements, 22 one-level disagreements, and 1% (3) two-level disagreementsdisagreements, and 1% (3) two-level disagreements

Now we thought we might have something – because Now we thought we might have something – because “Reliability begets validity” (Yarnold)“Reliability begets validity” (Yarnold)

Initial Adult-ESI StudyInitial Adult-ESI Study ValidityValidity

Hospitalization ratesHospitalization rates– 92% level 1 92% level 1 0% level 5 (table 3 page 239) 0% level 5 (table 3 page 239)

Composite resource intensityComposite resource intensity– Highly associated with ESI levels (table 3 page 239)Highly associated with ESI levels (table 3 page 239)

ED length of stay made sense by triage level (table 4)ED length of stay made sense by triage level (table 4) ED charges were moderately associated (table 4)ED charges were moderately associated (table 4)


Deb Travers of UNC Chapel Hill added to the study Deb Travers of UNC Chapel Hill added to the study group Jan 1999, just back from New Brunswick and a group Jan 1999, just back from New Brunswick and a visit with Dr. Bob Beveridge about the CTAS toolvisit with Dr. Bob Beveridge about the CTAS tool

Reliability and Validity of a New Five-Reliability and Validity of a New Five-Level Triage InstrumentLevel Triage Instrument::

AEM March 2000AEM March 2000

5544332211

3737101011000055

2222666655000044

111212818113130033

0011121284842222

000000004411

Nurse-prospectiveNurse-prospective

Phy

sici

an-r

etro

spec

tive

Phy

sici

an-r

etro

spec

tive

Weighted kappa=0.81, p<.001

Reference StandardsReference StandardsResources & OutcomesResources & Outcomes

labslabs x-rayx-ray ecgecg monitormonitor special studiesspecial studies fluids/parenteral medsfluids/parenteral meds consultationconsultation

Composite resource intensityComposite resource intensity Admission ratesAdmission rates *ED length of stay*ED length of stay ChargesCharges Case mixCase mix

Initial Adult-ESI Validation ResultsInitial Adult-ESI Validation ResultsResource Intensity-CompositeResource Intensity-Composite

0%

20%

40%

60%

80%

100%

1 2 3 4 5

many one none

Initial Adult-ESI Validation ResultsInitial Adult-ESI Validation Results Inpatient AdmissionInpatient Admission

1 2 3 4 50%

20%

40%

60%

80%

100%

1 2 3 4 5

LimitationsLimitations

Sampling bias Sampling bias – academic centersacademic centers– convenience samplingconvenience sampling– > 14 years of age only> 14 years of age only

Choice of outcomesChoice of outcomes

Related WorkRelated Work

““Triage: How long does it take? How long should it Triage: How long does it take? How long should it take?”:take?”: Travers: JEN 1999;25(3): 238-40Travers: JEN 1999;25(3): 238-40

““How reliable is emergency department triage?”: How reliable is emergency department triage?”: Fernandes, Wuerz et al: Ann. Em. Med. 1999;34:141-Fernandes, Wuerz et al: Ann. Em. Med. 1999;34:141-147147

““Re-evaluating triage in the new millennium: A Re-evaluating triage in the new millennium: A comprehensive look at the need for standardization comprehensive look at the need for standardization and quality.”: Gilboy, Travers and Wuerz: JEN and quality.”: Gilboy, Travers and Wuerz: JEN 1999;25(6):468-731999;25(6):468-73

ESI ESI ©© V 1 Implementation V 1 Implementation

April 1, 1999 UNC-Chapel Hill and April 15, 1999 @ April 1, 1999 UNC-Chapel Hill and April 15, 1999 @ The BrighamThe Brigham

ED leaderships decided to replace existing three-level ED leaderships decided to replace existing three-level triage with the new ESI © five-level triage algorithm triage with the new ESI © five-level triage algorithm

Nurses: 1.5 hour educational session included a Nurses: 1.5 hour educational session included a didactic presentation, a group discussion of triage didactic presentation, a group discussion of triage case scenarios, and a 20-case post-test with brief case scenarios, and a 20-case post-test with brief written descriptions written descriptions andand photos photos

Physicians: informed, not formally trainedPhysicians: informed, not formally trained

ESI ESI ©© V 1 Implementation V 1 Implementation

Posters and laminated pocket cards, computer-based Posters and laminated pocket cards, computer-based reinforcement were preparedreinforcement were prepared

The hospitals’ information systems, ED charts, and The hospitals’ information systems, ED charts, and ED patient tracking systems were updatedED patient tracking systems were updated

Change management strategiesChange management strategies were actively used, were actively used, including staff nurse involvement in planning, including staff nurse involvement in planning, implementation, communications, and post-implementation, communications, and post-implementation quality reviewsimplementation quality reviews

All new staff nurses received orientation using the All new staff nurses received orientation using the same implementation programsame implementation program

ESI ESI ©© V 1 Implementation V 1 ImplementationReliabilityReliability

Inter-rater Inter-rater reliabilityreliability was assessed using the post-test was assessed using the post-test case scenarios (n = 62 nurses: k .80) and a series of case scenarios (n = 62 nurses: k .80) and a series of independent paired triage assessments (n = 219: k .73)independent paired triage assessments (n = 219: k .73)

For the paired triage assignments there were 23% For the paired triage assignments there were 23% (51/219) one-level disagreements, 1/219 two level (51/219) one-level disagreements, 1/219 two level disagreementsdisagreements

ValidationValidation occurred on a one month cohort study: May occurred on a one month cohort study: May 1999 (May 1 – May 29, 1999: n = 8,251)1999 (May 1 – May 29, 1999: n = 8,251)

ESI ESI ©© V 1 Implementation: V 1 Implementation:ValidationValidation

Hospitalization rates were strongly associated with Hospitalization rates were strongly associated with triage leveltriage level– Level 1: 92% Level 1: 92% level 5 2% (figure 3 page 172) level 5 2% (figure 3 page 172)

* Median LOS was strongly correlated with triage * Median LOS was strongly correlated with triage level level – Two hours shorter at either extreme than in intermediate Two hours shorter at either extreme than in intermediate

categories (figure 3 page 172)categories (figure 3 page 172)

ESI ESI ©© V 1 Implementation: V 1 Implementation:Staff FeedbackStaff Feedback

Staff survey (in part):Staff survey (in part):– Easier to useEasier to use– More useful as a triage instrument than previous three-More useful as a triage instrument than previous three-

level triagelevel triage

ESI ESI ©© V 1 Implementation V 1 ImplementationApril 1999April 1999

Operational ImpactOperational Impact

Hard to display with dataHard to display with data– ““ESI triage categories determines the patients’ priority for ESI triage categories determines the patients’ priority for

treatment and also the physical location of care”treatment and also the physical location of care”– More about this after next data setMore about this after next data set

ESI ESI ©© V 1 Implementation V 1 Implementation LimitationsLimitations

Sampled only a portion of the cohort for paired triagesSampled only a portion of the cohort for paired triages Only two sitesOnly two sites (Only adults)(Only adults)

ESI ESI ©© V 1 Implementation V 1 ImplementationApril April 19991999

““Emergency Severity Index Triage category is Emergency Severity Index Triage category is associated with six-month survival”: Wuerz, For The associated with six-month survival”: Wuerz, For The ESI Study Group: AEM ESI Study Group: AEM 20012001;8(1)61-65 (;8(1)61-65 (JanuaryJanuary))

““Implementation and refinement of the Emergency Implementation and refinement of the Emergency Severity Index”: Wuerz, Travers, Gilboy, Eitel, Severity Index”: Wuerz, Travers, Gilboy, Eitel, Rosenau, and Yazari: AEM Rosenau, and Yazari: AEM 20012001;8(2)170-176. ;8(2)170-176. ((FebruaryFebruary))

““Dr. Richard Wuerz’s Emergency Severity Index” Dr. Richard Wuerz’s Emergency Severity Index” Walls: AEM 2001;8(2)183-184 (Walls: AEM 2001;8(2)183-184 (FebruaryFebruary))

ESI ESI ©© V 2 (All-Age) V 2 (All-Age) Multi-Site:Multi-Site: Summer Summer 19991999

Same five levels, explicit definitions Same five levels, explicit definitions Vital signs ancillary still (used to up-triage only, from Vital signs ancillary still (used to up-triage only, from

3 to 2)3 to 2) Peds criteria were added (potentially bacteremic) and Peds criteria were added (potentially bacteremic) and

vitals signs upgraded August 1999vitals signs upgraded August 1999 Research team in placeResearch team in place $50,000 AHRQ grant awarded in August 1999$50,000 AHRQ grant awarded in August 1999 Kick-off York Sept-Oct 1999: standardized staff Kick-off York Sept-Oct 1999: standardized staff

training program and case set; core project training program and case set; core project management steps management steps other sites other sites

Reliability & ValidityReliability & Validity

ReliabilityReliability: reproducibility & repeatability of a : reproducibility & repeatability of a measurement tool (instrument)measurement tool (instrument)– Inter-rater Inter-rater agreementagreement– Test-retest Test-retest agreementagreement

ValidityValidity: Or So What?: Or So What?– Predictive validityPredictive validity– Outcomes associated with each triage levelOutcomes associated with each triage level

Kappa =Kappa =statisticstatistic

Observed – expectedObserved – expected

1 - expected1 - expected

ReliabilityMeasurement of Agreement

Predictive Validity: OutcomesPredictive Validity: Outcomes

Outcomes Outcomes associated with each triage levelassociated with each triage level:: Composite resource intensityComposite resource intensity Admission ratesAdmission rates *ED length of stay*ED length of stay 60 day all cause mortality60 day all cause mortality Case mix (“footprint”)Case mix (“footprint”)

The ESI V. 2 Implementation, The ESI V. 2 Implementation, Reliability and Validity StudyReliability and Validity Study

(In Press: Accepted AEM April ‘03)(In Press: Accepted AEM April ‘03) Inter-rater Inter-rater reliabilityreliability (reproducibility) measured by (reproducibility) measured by

both case scenarios and patients in real timeboth case scenarios and patients in real time Prospective cohortProspective cohort study to identify outcomes study to identify outcomes

associated with each triage level (associated with each triage level (predictive validitypredictive validity):):– Resource intensity Resource intensity – Admit rates Admit rates – *ED length of stay*ED length of stay– 60 day all-cause mortality 60 day all-cause mortality – Case mix comparison between sites Case mix comparison between sites

““ESI V. 2… Is Reliable and Valid”ESI V. 2… Is Reliable and Valid” NOTE: Pre-publication information

Eitel, Travers, Rosenau, Gilboy, & Wuerz Seven EDs with > 350,000 annual visitsSeven EDs with > 350,000 annual visits

Mix of academic/community sitesMix of academic/community sites– Brigham & Women’s - BostonBrigham & Women’s - Boston

– Faulkner Hospital - Boston Faulkner Hospital - Boston

– Lehigh Valley - Allentown (3 sites)Lehigh Valley - Allentown (3 sites)

– University of North Carolina - Chapel Hill University of North Carolina - Chapel Hill

– York Hospital - YorkYork Hospital - York

Conclusion -Reliability:

ESI © triage produces reliable triage classification assignments when used by experienced and trained nurses at EDs representing varied regions of the country, urban and rural areas, and academic and community hospitals.

The Science of Triage

Conclusion – Predictive Validity:ESI © classification by experienced nurses reasonably predicts at triage how many resources patients will require to reach disposition BUT MORE IMPORTANTLY successfully discriminates low versus high resource intensity patients. This differentiation by resources requirements allows for much more effective streaming of patients post-triage into alternative operational pathways and\or care delivery settings: that is, parallel processing BUT NOT triage away.

Conclusion – Predictive Validity:ESI © triage produces admission rates by triage level that make sense.

Conclusion – Predictive Validity:ESI © triage classification assignments result in ED LOS numbers that (made) sense by triage level.

Conclusion – Predictive Validity:The data suggests that ESI © triage results in 60 day all-cause mortality rates that match up with the triage levels (*numbers are too small, too many missing data points).

Conclusion – Predictive Validity:ESI © triage produces presentational case mix information that is more representative of the operational reality of an ED than traditional three-level triage data – that is, triage case mix “footprints” are produced that make sense for differing EDs.

Conclusion – Predictive Validity:

Implementation of ESI © triage immediately provides reliable departmental case mix information that is useful to both clinical staff and ED & hospital managers for decision making.

“Measurement as a language…”

Kaplan


Definitions in ESI: face validity, explicit: understandable to everyone.

Reliability drives predictability. (So what?)

2yes

no

High risk situation?

Or

Confused/lethargic/disoriented?

Or

Severe pain/distress?

Step 3

Step 2:

Presentational Case Mix DataPresentational Case Mix Data(“can manage the waiting room…”)

8,063TOTAL

1.4 14%.003%812 (10%)Level 5

2.0 47%2%2,197 (27%)Level 4

3.4 73%24%3,173 (39%)Level 3

4.0 90%54%1,756 (22%)Level 2

2.4 80%73%125 (2%)Level 1

ED LOS

(hours)

Resource

Intensity

Admit

Rate

Case Mix

(% total)

Triage

Level


Definitions in ESI: face validity, explicit: understandable to everyone.

Reliability drives predictability. (So what?)

“The job of management is prediction.”

Dr. Deming

What does the What does the evidence indicate?evidence indicate?

ESI ESI ©© triage by experienced and trained ED triage by experienced and trained ED RN’s RN’s producesproduces reliable (reproducible and repeatable)reliable (reproducible and repeatable) &&

validvalid (predictable outcomes) (predictable outcomes) stratification of stratification of presenting patients into five classespresenting patients into five classes that provides that provides

case mix data useful to both ED case mix data useful to both ED andand hospital hospital managers formanagers for clinical,clinical, operational, and other operational, and other

(financial) decision-making.(financial) decision-making.

So what?

Driver of My InterestDriver of My Interest

““Reengineering The ED – Fixing Triage”: Streaming,Reengineering The ED – Fixing Triage”: Streaming,

not just sortingnot just sorting Predictive management and modelingPredictive management and modeling

Predictive Management and Predictive Management and Modeling :Modeling :

Operational Operational andand Financial Financial

Because “Because “ReliabilityReliability begets begets validityvalidity” (Yarnold) we can ” (Yarnold) we can be be predictivepredictive operationally AND financially (U.S.) operationally AND financially (U.S.)

See “Stuff Happens” flow chartSee “Stuff Happens” flow chart

– Basic operational modeling Basic operational modeling couldcould begin for the ED begin for the ED andand other pertinent downstream hospital service other pertinent downstream hospital service unitsunits

Predictive Management and Basic Predictive Management and Basic Operational ModelingOperational Modeling

““Stuff Happens” flow chartStuff Happens” flow chart

– What if the 4’s and 5’s do not go to the main ED? I.e. What if the 4’s and 5’s do not go to the main ED? I.e. when predicted volume justifies it, why not PLAN when predicted volume justifies it, why not PLAN ROUTINELY to have an EP and tech\nurse in an ROUTINELY to have an EP and tech\nurse in an “AlternaCare” setting: and care for 45-60 patients “AlternaCare” setting: and care for 45-60 patients (65,000 visit ED) with a two person doc-nurse team?(65,000 visit ED) with a two person doc-nurse team?

– Parallel processing Parallel processing unloadunload the main ( the main (overcrowdedovercrowded) ) ED ED and make a and make a palpable palpable difference operationallydifference operationally……

If your little girl falls and cuts her If your little girl falls and cuts her forehead and needs stitches - forehead and needs stitches -

is that an emergency?is that an emergency?

0

2

4

6

8

10

12

No

. O

f P

hy

sic

ian

s In

ED

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Av

era

ge

Pa

tie

nt

Arriv

als

Pe

r H

r

7A 9A

11A 1P

3P 5P

7P 9P

11P 1A

3A 5A

ED Physicians Avg Weekday Arrivals

York Hospital Emergency DepartmentPhysician Staffing Vs Average Arrivals

0

2

4

6

8

10

12

No

. O

f P

hy

sic

ian

s In

ED

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Av

era

ge

Pa

tie

nt

Arriv

als

Pe

r H

r

7A 9A

11A 1P

3P 5P

7P 9P

11P 1A

3A 5A

ED Physicians

Avg Weekend Arrivals

York Hospital Emergency DepartmentPhysician Staffing Vs Average Arrivals

Predictive Management and Basic Predictive Management and Basic Financial Modeling (U.S.)Financial Modeling (U.S.)

What are the What are the financialfinancial implications for alternative implications for alternative staffing considerations for decisions regarding staffing considerations for decisions regarding operating AlternaCare?operating AlternaCare?– Understand Understand professional sideprofessional side reimbursement by RBRVS reimbursement by RBRVS andand

otherother 3 3rdrd party payors, for EP’s (good) vs. Advanced Practice party payors, for EP’s (good) vs. Advanced Practice Providers – APP’s (often not so good)Providers – APP’s (often not so good)

– Understand state licensing rules for APP’s for Allopathic vs. Understand state licensing rules for APP’s for Allopathic vs. Osteopathic State Boards of Medicine (complex – doable)Osteopathic State Boards of Medicine (complex – doable)

– Understand the credentialing hoops required by all your 3Understand the credentialing hoops required by all your 3rdrd party payors for reimbursement for services of APP’s in the party payors for reimbursement for services of APP’s in the ED setting (complex\very time consuming)ED setting (complex\very time consuming)


““What are the What are the financialfinancial implications for alternative implications for alternative staffing considerations for decisions regarding staffing considerations for decisions regarding AlternaCare?AlternaCare?– Payor mix: understand Payor mix: understand hospital sidehospital side reimbursement for reimbursement for

Medicare APC’s (3 year’s new) (good IF…) vs. all the other Medicare APC’s (3 year’s new) (good IF…) vs. all the other other 3other 3rdrd party payors: party payors: ? % are Medicare in “AlternaCare”? % are Medicare in “AlternaCare”

– Service mix: understand that usually 65-70% or so are “boo-Service mix: understand that usually 65-70% or so are “boo-boo’s”, or trauma relatedboo’s”, or trauma related» Are minor surgical procedures paid for fairly well by most Are minor surgical procedures paid for fairly well by most

33rdrd party payors? party payors?


Because “Reliability begets validity” Because “Reliability begets validity” can be predictivecan be predictive See “Medicare Fee Schedule”: visit and procedure See “Medicare Fee Schedule”: visit and procedure

codes – financial modeling also for the EDcodes – financial modeling also for the ED NoteNote: RBRVS “E&M” approach for Emergency : RBRVS “E&M” approach for Emergency

Physicians vs. “E&M” for all other physicians are Physicians vs. “E&M” for all other physicians are different!different!

Advanced Operational Modeling: Advanced Operational Modeling: Computer Assisted DesignComputer Assisted Design

Once Once reliablereliable case mix (service mix) information exists case mix (service mix) information exists in any service settingin any service setting

CAD with flow chart-based off-the shelf software can CAD with flow chart-based off-the shelf software can be brought to the shop floor to assist with resources be brought to the shop floor to assist with resources deployment decision makingdeployment decision making

Activity analysis + operational logic + simulationActivity analysis + operational logic + simulation

YH ED Simulation StudyYH ED Simulation StudyPartial Question SetPartial Question Set

What is the optimal staffing pattern and skill mix by What is the optimal staffing pattern and skill mix by time of day and day of week for the emergency time of day and day of week for the emergency department?department?

What are the performance characteristics of What are the performance characteristics of AlternaCare – financial, throughput times – when AlternaCare – financial, throughput times – when the primary provider is a Physician Extender versus the primary provider is a Physician Extender versus an Emergency Physicianan Emergency Physician

What are the optimal hours of operation for What are the optimal hours of operation for AlternaCare by day of the week?AlternaCare by day of the week?

YH ED Simulation StudyYH ED Simulation Study Partial Question Set Partial Question Set

How will the performance of the ED and How will the performance of the ED and AlternaCare be affected by adding four additional AlternaCare be affected by adding four additional care areas to AlternaCare?care areas to AlternaCare?

What is the impact on operations – flow, resource What is the impact on operations – flow, resource consumption, staffing and revenue – of holding consumption, staffing and revenue – of holding admitted patients for 8, 16, and 24 hours by number admitted patients for 8, 16, and 24 hours by number of patients held – 5, 10, 15, and 20 patients?of patients held – 5, 10, 15, and 20 patients?

What is the impact of medical students on ED What is the impact of medical students on ED performance?performance?

Predictive Management and Predictive Management and Advanced Operational ModelingAdvanced Operational Modeling

““Pairing ESI © Five-level Triage Case Mix Data With Pairing ESI © Five-level Triage Case Mix Data With Computer-Assisted Design To Improve ED Access and Computer-Assisted Design To Improve ED Access and Throughput”: Mahapatra, Koelling, Eitel & Grove (In Throughput”: Mahapatra, Koelling, Eitel & Grove (In press)press)– YH academic ED modeled in Process Model (low fidelity) & YH academic ED modeled in Process Model (low fidelity) &

ARENA (high fidelity) models ARENA (high fidelity) models – Invited presentation @ The Winter Simulation ConferenceInvited presentation @ The Winter Simulation Conference

New Orleans December 2003New Orleans December 2003– BMLS 2004 course BMLS 2004 course


A principal goal of Triage should be: A principal goal of Triage should be: To determine who should be seen first. To determine who should be seen first.

Right?Right?

A second major goal should be:A second major goal should be:Not just to “sort” but to “stream”Not just to “sort” but to “stream”

to get the right patient to the right to get the right patient to the right resources in the right place and at the resources in the right place and at the right time right time

Managing by Managing by flowflow, , Not capacity!Not capacity!

“The Goal”

To manage by To manage by flowflow, , have to first decide have to first decide

how to how to stream stream incoming patientsincoming patients

What does the What does the evidence indicate?evidence indicate?

ESI ESI ©© triage by experienced and trained ED triage by experienced and trained ED RN’s RN’s producesproduces reliable (reproducible and repeatable)reliable (reproducible and repeatable) &&

validvalid (predictable outcomes) (predictable outcomes) stratification of stratification of presenting patients into five classespresenting patients into five classes that provides that provides

case mix data useful to both ED case mix data useful to both ED andand hospital hospital managers formanagers for clinical,clinical, operational, and other operational, and other

(financial) decision-making.(financial) decision-making.

We suggest you acquire:

*“The ESI © Five Level Triage Implementation Handbook” available the week of July 7, 2003 from the

ENA ($50-100) www.ena.org.

*Authored by The ESI Research Team Dedicated to the memory of Dr. Rich Wuerz

Read it.

Talk seriously with your ED management team and senior hospital managers about the important downstream implications it could have for caregivers and managers in terms of predictive management and modeling.

Then – thoughtfully – install ESI © five level triage in your ED and begin a movement towards a Hospital Emergency Care System.

In Memory Of:In Memory Of:Richard Wuerz MD Richard Wuerz MD

Associate Clinical DirectorAssociate Clinical Director

Department of Emergency MedicineDepartment of Emergency Medicine

Brigham and Women’s Hospital Brigham and Women’s Hospital

Harvard Medical School Harvard Medical School

Richard C. Wuerz, MD1960-2000

On Behalf Of The ESI Triage Research Team:On Behalf Of The ESI Triage Research Team: Nicki GilboyNicki Gilboy

Alex RosenauAlex Rosenau

Debbie TraversDebbie Travers

Tom Stair (the database guru)Tom Stair (the database guru)

Melissa SchlenkerMelissa Schlenker

Dave EitelDave Eitel

Rich WuerzRich Wuerz

Thank you for the invitation!Thank you for the invitation!

Triage: Fixing the Front EndTriage: Fixing the Front End

Emergency Nursing SeminarEmergency Nursing SeminarThe 2The 2ndnd Mediterranean Emergency Medicine Mediterranean Emergency Medicine

CongressCongress

David Eitel MD [email protected]

Documents

Triage: Fixing the Front End Emergency Nursing Seminar The 2 nd Mediterranean Emergency Medicine Congress David Eitel MD MBA [email protected]