Issue 2 : Registration-Triage

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Problem definition: Inefficient registration-triage sequence at the ER: patients go to the front desk and are asked to describe their pain, to remember names and doses of medications they are currently taking and to fill out a form. After giving the hospital the information (if they are able to remember it correctly), they are told to sit and wait until a nurse calls them to be triaged. There can be more efficient ways to triage patients at the same time that the hospital collects their basic information (think about critic cases in which time is really a factor). The time that patients invest in providing the information can be saved if they go through an initial triage assesment as soon as they get into the ED. The initial assesment will direct the patients to a fast track area or to an emergency area depending on their acuity level and then registration can properly take place in any case. Sorting and redirecting patients from the very beginning also helps to better manage wait times and use of resources.

Research:

Two practices found to improve the time patients wait to be seen are:

a) Triage-driven bed placement (a mini-registration asking the patient his name, birth date and SSN). Complete registration is done later at the bedside [Karpiel, 2004].

b) Triage-team method [Perrone, 2006]in which a team composed by a receptionist, a nurse and a doctor see patients when they arrive at the ED. The team will determine the urgency, interview the patient, order necessary tests and send the patient to the next phase.

Simulation is another tool that can help to make improvements in the system once the bottlenecks have been identified [Chick,2003].

Kiosks [4] to automate the registration process, decrease wait times, ensure the security of the patient data and faster identification of acuity patients. Another benefit is that the information is captured in the system so if the patient visits the ER in subsequent occasions he will not need to remember all the medications taken previously.


How can the problem be measured?: The hospital can take the current average waiting time for patients to be triaged and the avg number of patients waiting to be traiged to have a basis to compare. After that, if they implement the initial assesment method, they could measure the average time and number of patients in the fast track area and emergency area. There should be an improvement in times. Also, they could measure if there has been any increase in throughput as a result of more efficient registration/triage sequence.

Also, asking patients about their experience: were they seen immediately by the triage team and then redirected to fast track or emergency care?, did they have to wait to be seen by the traige team?, was it helpful to have the information of previous visits stored (accuracy in names and doses of medicines they have been taking)?

References:

1) Karpiel, Marty. Improving Emergency Department Flow. Healthcare Executive, Jan/Feb 2004, 19, 1, AB/INFORM GLOBAL, pg 40.

2) Perrone, L. et. al. Simulation model for improving the operation of the emergency department of special healthcare. IEEE Proceedings of the 2006 winter simulation conference.

3) Chick, S., et.al. The use of simulation to reduce the length of stay in an emergency department. IEEE Proceedings of the 2003 winter simulation conference.

4) http://vecnamedical.com/medical/qckiosk/index.shtml

COMMENTS: Ackerman Registration is the creation of the infrastructure (such as patient ID number and encounter number) needed to track the patient and any tests throughout the visit. It is a non-trivial task and errors in this process cause a cascading set of potential for errors. When I search our electronic medical record by name there are frequently multiple medical record numbers under that name - some of them may correspond to the same patient who was misregistered on one of their visits, some of them may refer to another patient entirely. Social security numbers are frequently mistranscribed and are all to often "borrowed" or even made up on the spot by some patients. Medications and allergies change and not having that information can produce lethal results.

Is the problem that the person behind the counter isn't friendly? Or is it that the patient isn't told what happens next or how soon it is going to happen? Is this a problem with registration or triage?

Asking people what they think is fine but... isn't there something more quantifiable? One of the difficulties of doing research by survey is proving that the data you gathered actual is a measure of the question you are asking. There is good data on Press-Ganey scores suggesting that admitted patient's sense of the quality of the care they recieved is more dependent on the perceived quality of the food service than any clinical outcome measure. Many hospitals now offer detailed menus with a waiter taking your orders and deleivering your food. It turns out this is a relatively inexpensive way to improve Press-Ganey scores without fixing any of the bigger problems that might be present in a hospital. Consider tracking misregistration rates, overall throughput rates, time to completion of the registration step actual versus perceived times.

Registration is a complex task that actual begins the triage process. Some elements included in the registration process actually legally must be done particular ways (EMTALA raises its head here). Gathering insurance information and things like that must be done as a delayed process or a clearly parallel process to clinical evaluation because it is illegal to delay medical evaluation to ask for or verify insurance information (that doesn't mean they can't ask you while you are waiting if you were going to be waiting anyway...).