Decreasing Emergency Department Door to Triage Time with Evidence-Based Process

Aim: : Triage is the pivotal component of a patient’s emergency department (ED) course. EDs have demonstrated low triage accuracy and an increase in door to triage time, which significantly impacts quality of patient care, healthcare costs, and patient satisfaction. Evidence-based triage education, such as the ENA ESI course, is critical to providing accurate, high quality triage. The aim of this quality improvement (QI) project was to decrease door to triage times for adult ED patients with a chief complaint of chest pain by 20% from 18 minutes to less than 15 minutes in 3 months.

Framework:: The Model for Improvement with Plan-Do-Study-Act Cycles was used to design and guide this quality improvement project.

Setting:: The QI initiative took place in the ED of a midwestern urban, academic, healthcare center from October 1, 2022 and December 31, 2022.

Stakeholder Team:: Core team members included the QI project leader who identified the quality gap, developed a focused triage education module, and collected data, ED leadership who supported project production and assisted with participation recruitment, ED informatics team, and ED staff RNs, nurse practitioners, and physicians who voluntarily participated in the project.

Methods: : ED RNs, nurse practitioners, and physicians voluntarily completed an anonymous pre-implementation survey which collected baseline demographics and assessed ED ESI/triage knowledge and AHA Chest Pain Guidelines (case studies and quiz) via the Qualtrics web-based platform. Participants then reviewed an evidence-based narrated PowerPoint presentation summarizing ENA ESI/Triage and AHA Chest Pain Guidelines. Immediately following the education, participants completed a post-implementation survey and quiz similar to the pre-implementation survey and quiz Qualtrics to assess changes in knowledge. Data analysis was performed using Qualtrics and the EMR (EPIC Slicer Dicer). EPIC Slicer Dicer allows customizable data reporting, analytics and exploration for patient populations.

Outcomes:: Preliminary data in the quiz scores demonstrated participants improved triage accuracy, however they tended to under triage patients more than over triage. Door to triage times for patients presenting to the ED with chest pain did decrease, however they did not decrease by the goal of 20%. There was improvement in door to EKG times and also in overall participant scores in the post-implementation quiz. A significant number of participants reported an increased level of confidence in their triage skills after viewing the education.

Implications:: This project supports the need for continuing education of ED ESI/triage. The results also highlight the urgency to address the impacts of triage accuracy, door to triage times for all patients, and the perception that triage is a vital component to a patient’s ED course. As triage accuracy and door to triage times improve, there may be an opportunity to expand and improve other important ED metrics.