Pediatric Emergency Department Triage Workflow Improvement

Aim: : Workflow inefficiencies identified by the Emergency Department (ED) nurses in the triage space led to concerns regarding confidentiality, infection prevention and nurses’ cognitive burden, as well as patient and family dissatisfaction. The triage area is space-constrained. The workflow did not scale effectively to increased patient volume and there was no reliable identification and throughput based on patient acuity. The aim of this project was to redesign and streamline the ED triage process to increase access to care, improve outcomes and enhance patient, family, and employee satisfaction.

Framework:: Quality improvement project using Enterprise Project Management and DMAIC Lean Six Sigma methodology.

Setting:: Pediatric level I trauma center located in the Northeast.

Stakeholder Team:: A multidisciplinary group was developed with ED nurses, clinical assistants, patient experience representatives, family advisory council members, security, infection prevention and control, clinical informatics, the simulation team and the Enterprise Project Management Team.

Methods: : The DMAIC Lean Six Sigma method was used to describe the current state, identify pain points, create a root cause analysis, brainstorm solutions and prioritize implementation. Direct current state observations were completed across varying shifts with varying patient volume. A tabletop brainstorming activity was completed with the support of the simulation team; a three-step redesign approach was created. Arrival to triage completion data were collected and a new arrival to screening completion data set was created.

Outcomes:: Quick wins were identified and implemented. Floor markers for queued patients were placed to increase social distancing and promote visualization for the screener nurse. Paper charting was eliminated and an electronic screening form was implemented. Using the electronic screener acuity score, a workflow was implemented that supported throughput of patients based on acuity rather than arrival time. An electronic workflow for identifying the patient’s location in triage was also initiated. Triage documentation was assessed and streamlined to avoid duplication. Since initiation of the electronic screener form, patient arrival to screener form completion has consistently been greater than 95% complete in less than 10 minutes. Since the triage documentation revision, timing of triage documentation completion within 30 minutes has increased from 65% to 75%. Anecdotal feedback from ED staff and families included that the workflow changes improved communication, throughput, and satisfaction.

Implications:: Creating a standardized triage workflow improves early detection of acute patient arrival, improves patient throughput and staff, patient, and family satisfaction. Adoption of electronic solutions has improved departmental communication and awareness of patients waiting to be seen. Implementation of an electronic screener form allows data collection of initial nursing assessment after patient arrival. Appropriate technology integration with workflow changes helped with early adoption and sustainability. Table-top simulation sessions helped participants visualize complex workflows. The use of a multidisciplinary team led to participatory brainstorming and acceptance of workflow changes. Future technological recommendations include electronic kiosk check-in and mobile phone texting to communicate with families. Future environmental changes to the triage and waiting room areas are recommended to segment the ED patient population by acuity to create a treatment space for low acuity patients and a safe waiting area for behavioral health patients.