Initiating Early Patient Care Through Team Triage and Treatment
Inova Fairfax Hospital is a 753-bed regional medical center in Northern Virginia, just outside of Washington, D.C. As recently as one year ago, the facility faced daunting challenges, including an emergency department (ED) that was overcrowded 79 percent of the time compared to a national average of only 21 percent.
The reasons for this were fairly obvious. Like many safety net hospitals across the country, Inova Fairfax Hospital is a Level 1 trauma center that is the busiest in the region, a teaching facility for multiple local medical and nursing schools, a tertiary care facility, a pediatric emergency care center and also, very importantly, a community hospital.
The hospital's ED sees more than 70,000 patients during the average year - many of whom are not critically injured, but who instead arrive needing a few stitches or an arm that should be x-rayed for a possible fracture. Of course, these are the patients who often need to wait while those more critically injured are taken into Level 1 trauma - thus instigating Inova Fairfax Hospital's creation of Team Triage and Treatment (T3) through funding provided by an Urgent Matters grant from The Robert Wood Johnson Foundation.
"We're fortunate in that Inova is an organization that innovates frequently," said Dr. Thom Mayer, chair of the Department of Emergency Medicine at Inova Fairfax Hospital and leader of the committee that developed and implemented Inova's unique T3 approach. "We're part of a culture that regularly pushes the envelope. Inova literally means innovative healthcare."
The idea generated from data showing that there are predictable times during which the number of patients waiting in the ED outnumber the rooms in which ED patients may be seen. Interestingly, Dr. Mayer and his committee also found that more than 30 percent of ED patients never need a room at all, because their injuries are such that they may be evaluated and treated in triage before they ever get into a room.
Prior to the implementation of T3, patients' experiences in the ED at Inova Fairfax Hospital were fairly typical to those of patients at similar facilities nationwide. If someone came into the hospital with a broken arm, he or she would be approached by a triage nurse, who would evaluate the patient's condition and likely provide an over-the-counter pain reliever. The individual would be registered, and then the wait for an available room would begin. It could be only a few minutes if it was a quiet morning in the ED, but it could also be hours.
The key to this new and different program at Inova Fairfax Hospital is the word 'team.' T3 deploys:
The five member team work together and begin an ED patient's evaluation and treatment at the point of contact in triage. The scribe helps by writing or typing everything the physician says and the technical assistant helps with tasks such as order-entry. A registrar is also an important member because, like in many hospitals, it is very difficult to get things done if the patient is not registered and in the hospital computer system.
T3 was implemented during 10 hour shifts, from 10:00am to 8:00pm, to match Inova's peak flow. Weekly trials and assessments of the initiative allowed for adjustments and fixes during the pilot period (rapid cycle change methodology); they did not wait till the end of the pilot to incorporate the necessary changes. For example, registration was added during the trial period. Overall, the pilot initiative represented over 150 hours.
Under the T3 approach, the same patient with only a minor fracture in his or her arm would instead be immediately seen by the five-member team. Dr. Mayer explained how the approach differs, "The five-member Team Triage is going to provide pain reliever, give the patient an x-ray, put him in a sling and call the orthopedics office about putting on the appropriate splint. All of this can be done in the triage area, and the patient would probably come and go before he'd even have been put into a room under the old system."
Measuring T3's Success
Dr. Mayer's committee had a number of hypotheses about the proposed T3 approach:
To appropriately evaluate the program's effectiveness, Dr. Mayer and his committee put a number of data sources in place, including a patient survey, a staff survey, chart reviews of turn-around times, a cost-benefit analysis, reports on patient safety occurrences and more.
To the program's credit, each of the committee's above hypotheses have been proven correct through the implementation of T3. Once the trial T3 program was fully up and running, an average of 4.7 patients per hour were being seen by T3, compared with previous per clinician averages ranging from 1.6 to 2.7 per hour.
Patient Satisfaction Survey Results
Turn Around Times
I'd say that it's been somewhere between very successful and spectacularly successful," said Dr. Mayer.
Because the T3 program has achieved or exceeded all of its goals, Inova Fairfax Hospital is now trying to support the program several days a week without supplemental funding from the Urgent Matters grant - with the hopes that the program can be continued long-term.
For other emergency departments considering implementation of such a program, Dr. Mayer's advice is unconventional - take your biggest critic and put him or her on your planning committee, so that the person has the opportunity to voice early on why it won't work. Asked if there is anything Inova should have done differently in its approach to T3, Dr. Mayer's comment is a resounding one, "I just wish we would have done it five years ago."
Thom Mayer, M.D., Chair, Department of Emergency Medicine, Inova Fairfax Hospital, Fairfax, VA