No waiting

November 1, 2010
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View from physician area in triage to nursing area in triage. Scott Spitzer Photography & Design. Patient evaluation area at arrival (triage). Scott Spitzer Photography & Design. Triage/arrival organization. Courtesy of EwingCole. Bubble diagram of ideal area relationships. Courtesy of EwingCole. View from staff area to public and private results lounges. Scott Spitzer Photography & Design. Private results lounge off main lounge. Scott Spitzer Photography & Design. Arrival zone at triage station. Scott Spitzer Photography & Design.
According to a recent study published by the Journal of the American Medical Association, visits to the emergency department have increased by 23% in 10 years-almost double what would be expected due to population growth. It's tough to afford healthcare insurance; it's also hard to get in to see a primary care physician immediately. A visit to the ED solves both problems for a lot of people, but creates another: People must wait for hours in the overpopulated ED.

As a healthcare provider, how do you get patients in and out quickly? A novel approach in emergency departments around the country puts doctors at the front of the house to evaluate patients for the urgency of their condition when they first arrive. Physician's assistants, nurse practitioners, and physicians examine the more serious cases. Patients waiting for test results or whose care can be delayed are upright, dressed, and reading magazines in a comfortable lounge, rather than prone, gowned, and impatient in a treatment bed.

While attempts at this approach have failed in the past, innovative methodologies such as Physician-Directed Queuing (PDQ); Rapid Medical Evaluation; Physician in Triage; or Rapid Assessment, Triage, and Efficient Disposition are making a difference and being deployed by hospitals to address crowding. The success of this process depends greatly on core process redesign. Process redesign was once an anomaly, but now this operating method for the ED is being adopted more widely and improving with each iteration. To support this new procedure, there are a number of design strategies that should be considered.

Path of minimal exigency

The goal of the triage process has not changed due to the insertion of a physician to the process. However, the addition of a physician to the team allows the process to develop even further.

Although exact methodologies vary at this point, two basic paths have developed. Upon presentation, urgent patients who require all emergency department resources are sent to the core of the emergency department for treatment. Also called “horizontal patients” due to their typical position during treatment, they may be tested and scanned on their way to the treatment room. The treatment of these patients then proceeds much as it has in most emergency departments for the past decade: The patients may be registered at bedside, evaluated, and treated in an exam room while lying on a stretcher, and then discharged or admitted to the hospital.

The new, alternate paths are developing for non-urgent patients. While traditional “fast-track” or “quick-care” areas segregate by acuity, other innovative methodologies are segregating by resource or even completing low-resource evaluations upon arrival. With these “vertical patients,” the objective is to give them access to the resources they need without ever having to enter the core of the emergency department and occupy a bed. In the PDQ methodology, at triage, non-urgent patients are divided into those who need additional diagnostic testing and those who can be dispositioned without additional testing. Those not requiring testing are quickly treated in triage or nearby exam rooms, then registered and discharged. Physical plant design is crucial to the long-term success of these process innovations.

For those patients requiring diagnostic testing, the physician writes the order, tests are administered, and the patient returns to a results lounge. After the results are reviewed, treatment is given and the patient is discharged. Key elements of the process are having the right waiting spaces available, using those spaces to queue for results, and not using the treatment space as a waiting room.

Designing for treatment

The first visible design change should be made in the triage area or arrival zone, which must be spacious enough for a four-person team. The team, at minimum, includes a physician, a triage nurse, a tech, and a representative from registration. The area should allow each individual adequate working space with the physician area close enough to the triage nurse to be able to provide support when necessary. Ideally, in the PDQ model, the physician location should allow both visual and audible observation of the triage process. Preferably, the area also should allow for observation of walk-ins and ambulance arrivals.

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