Fixing the Front End: Using ESI Triage v.4 To Optimize Flow
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1 Fixing the Front End: Using ESI Triage v.4 To Optimize Flow David Eitel MD MBA For The ESI Triage Research Team
2 In Memory Of: Richard Wuerz MD Associate Clinical Director Department of Emergency Medicine Brigham and Women s Hospital Harvard Medical School
3 Richard C. Wuerz, MD
4 On Behalf Of The ESI Triage Research Team Dave Eitel Nicki Gilboy Alex Rosenau Paula Tanabe Debbie Travers Rich Wuerz Thank you for the invitation!
5 The ED Problem ED Triage -? ESI Triage Background Introduction» History and development Make clear the ESI versions (4); show a couple of major highlights from our work
6 ESI Triage Introduction What it is and how it is implemented What s new in version 4 What you can do with it once it s implemented How to get ESI v.4 from the AHRQ Implementation manual Training video At no cost
7 THE ED Problem
8 Emergency Medicine Explained 1 patient arrives 2 stuff happens 3 patient leaves
9 U.S. Emergency Department Visits The Good News! Millions of visits
10 The Bad News U.S. GAO, 1993 emergent 17% urgent 40% 43% non-urgent
11 The Emergency Department Problem Silver, Manegold, JAMA Oct 24, 1966 ED visits rose 175% from % nonurgent problems Factors contributing to the problem : Mobility (no primary doctor) Difficulty finding a physician at night! Indigent populations 24/7 diagnostic facilities at hospital
12 Health Care Debate and through the 1990 s the most costly care of all (Mr. Clinton) Marginal costs of minor emergencies = $25 (Bob Williams) Use of ED as source of primary care ongoing 43 M without health insurance Insurance card does not equal access Definition of emergency Prudent layperson language
13 Definition of emergency life threat life or limb threat results in hospital admission or operation requires care within 2 hours requires care within 24 hours severe pain my lawyer sent me in to get checked
14 Cost Other ED Problems Perception that we cost way too much Quality\Satisfaction Variation in timeliness to care perceived by ED patients Single biggest thing ED patients complain about is wait time Now overcrowding: access block by Aussies Safety and nursing exodus
15 What is ED triage? Why do we do it?
16 What does ED triage have to do with any of this anyway?
17 ESI TRIAGE: Background
18 Driver of My Interest Operations Management: Reengineering 101 ( 94) Pick a business that s in trouble (The YH ED) Identify it s key business processes (?) If something is broken FIX IT! Every one did it, but everyone did it differently even the same nurse later
19 Driver of My Interest Team paper Reengineering The ED Fixing Triage : Streaming, not just sorting Predictive management and modeling ESI was developed (Wuerz and Eitel) so we could flow [map] and then model the ED
20 Services vs. Products We in health care delivery are in a service business and must begin to manage it as such. There is a science of services management, within the discipline of operations management. We should begin to train our hospital/health care managers in the core concepts, content and tools of services management. Just released report form National Academy of Sciences: Building a Better Delivery System: A New Engineering/Health Care Partnership.
21 Services vs. Products Recommended Reading Service Management 3 rd Edition Fitzsimmons ISBN x Ch 10 Forecasting Demand For Services Ch 11 Managing Waiting Lines Ch 12 Queuing Models (Server) & Capacity Planning Ch 13 **Managing Capacity & Demand
22 ESI TRIAGE: Development
23 BWH Triage Guidelines Emergent: 1% before 4/99 requires immediate evaluation & treatment Urgent: 65% can tolerate a period of time in the waiting room Non-urgent: 35% minor illness/injury that can be treated within six hours
24 Emergency Nurses Association Emergent/1: Life- or limb-threatening illness/injury Urgent/2: Requires prompt care, but will not cause loss of life or limb if left untreated for several hours Non-urgent/3 urgent/3: Time is not a critical factor; minor illness or injury
25 Triage Data Report YH ED 1997 TRIAGE VOLUME % ADMIT % Jan-Apr 97 18,029 visits 22 % admits Level 1 Level 2 Level ,577 13,150 2 % 25 % 73 % 69 % 51 % 11 %
26 Inconsistency of Triage Wuerz: Ann Emerg Med Oct nurses, two academic EDs triaged 5 standardized patients scenarios using their three-level scale scales Between raters: only 35% agreement beyond chance Test-retest: repeat triage of same cases only 25% triaged the same both times Conclusion: the instrument is too blunt! (no instrument )
27 What Else Is Out There? Australian National Triage Scale-1994 Canadian Triage and Acuity Scale-1996 Manchester Triage-1997
28 to see a This patient can wait no longer than to see physician Australian & Canadian Triage Triage level NTS 0 min 10 min 30 min 60 min 120 min CTAS 0 min 15 min 30 min 60 min 120 min
29 What is ED triage? Why do we do it?
30 A principal goal of Triage should be: To determine who should be seen first. Right?
31 If that is the only question asked How long do you think everyone should/could wait?
32 A second major goal: should be not to just sort but to stream to get the right patient to the right resources in the right place and at the right time
33 The Triage Game! Observation: if case scenarios were given - what will this patient need nurses were in agreement
34 There are big emergencies,, and there are little emergencies P.S. Experienced ED nurses are excellent at this! (especially those potentially big emergencies )
35 If your little girl falls and cuts her forehead, her face is all bloody, and she needs stitches - is that an emergency?
36 ED Triage - is not just about time: It s about resources!
37 Manage by thinking flow 1st, not capacity 1 st (beds). The Goal by Goldratt
38 To manage by flow, have to first decide how to stream incoming patients
39 In ESI triage two questions are asked: Not only who should be seen first, But also, what does the patient need, in terms of resources, to reach a disposition?
40 Those in need of few resources but the doc- nurse team can bypass the main ED. The parallel processing of patients can occur if patient categorization is done reliably.
41 The Bad News U.S. GAO, 1993 emergent 17% urgent 40% 43% non-urgent
42 The ESI V. 1 Triage Algorithm Over time: five levels, explicit definitions, logic embedded in complex tables In August 1998 Breakthrough: flowchart-based algorithm (Tufte) Adults only in ESI v.1 ( > age 14)
43 patient dying? no shouldn t wait? yes yes 1 no how many resources? none one many vital signs 3 no yes
44 Vital Sign Criteria To Up-Triage No clear consensus in the literature on abnormal vitals SIRS (not SARS) criteria adopted
45 Reliability & Validity Reliability: : reproducibility & repeatability of a measurement tool (instrument) Inter-rater rater agreement Test-retest agreement Validity: : Or the So What? question: Predictive validity Reliability begets predictability Operational outcomes associated with each triage level
46 Retrospective Work Completed October-December 1998 Produced the Following Paper: Reliability and validity of a new five-level triage instrument : Wuerz, Milne, Eitel, Travers, and Gilboy: AEM 2000;7(3):
47 Reliability and Validity of a New Five- Level Triage Instrument: Physician-retrospective AEM March 2000 Nurse-prospective Weighted kappa=0.81, p<.001
48 Initial Adult-ESI Validation Results Inpatient Admission 100% 80% 60% 40% 20% 0% Operational outcomes that made sense by triage class
49 ESI v.1 (Adult) Implementation April 1, 1999 UNC-Chapel Chapel Hill and April 15, The Brigham ED leaderships decided to replace existing three-level triage with the new ESI five-level triage algorithm Nurses trained 1.5 hour standardized educational package included a didactic presentation, a group discussion of triage case scenarios, and a 20-case post- test and photos; everyone was informed This is how you too should implement ESI Triage
50 ESI v.2: All-Age Age 1999 Same five levels, explicit definitions Peds criteria were added (potentially bacteremic) ) and vitals signs upgraded August 1999 Research team in place $50,000 AHRQ grant awarded in August 1999 Multi-site implementation of ESI v.2
51 That Multi-Site Implementation Resulted In This Paper: Eitel D, Travers D, Rosenau A, Gilboy N, Wuerz R. The Emergency Severity Index Triage Algorithm Version 2 is Reliable and Valid. Academic Emergency Medicine. 2003; 10(10)
52 60% Case Mix by Site % Patients 50% 40% 30% 20% 10% BW FH 17th MH YH UNC LVCC 0% ESI Triage Level
53 ESI TRIAGE DEVELOPMENT Version 2 vs. 3
54 patient dying? no shouldn t wait? yes yes 1 no how many resources? none one many vital signs 3 no **consider
55 ESI TRIAGE v.3 DISTRIBUTION ENA Handbook
56 The Emergency Severity Index Implementation Handbook: A Five-Level Triage System/ authored by: Nicki Gilboy, Paula Tanabe, Debbie A. Travers, Alex Rosenau, and David Eitel The Emergency Nurses Association [ENA] DesPlaines, IL: 2003 Contains ESI v.3 (consider) THIS IS NO LONGER AVAILABLE FROM THE ENA ESI v.4 IS OUT & WITH A NEW PUBLISHER
57 ESI TRIAGE: What s New In Version 4?
58 What s new in ESI Version 4? Level 1 Criteria Expanded Tanabe et al AEM June 2005» Refining Emergency Severity Index Triage Criteria. Pediatric Fever Criteria Updated
59 ESI Triage Algorithm v.4 requires immediate life-saving intervention? A yes 1 no high risk situation? or confused/lethargic/disoriented? or severe pain/distress? B yes 2 ESI Triage Research Team 2005
60 ACEP s Pediatric Fever Criteria Adopted The American College of Emergency Physician s Clinical Policy for Children Younger than 3 Years Presenting to the Emergency Department with Fever 2003 guidelines are included
61 What Can You Do With ESI Triage?
62 The job of management is prediction. Dr. Deming Reliability begets predictability
63 ESI Triage Algorithm v.4 requires immediate life-saving intervention? A yes 1 no high risk situation? or confused/lethargic/disoriented? or severe pain/distress? B yes 2 ESI Triage Research Team 2005
64 Real Time Management of Patient Flow Level 1 s and 2 s go to your critical care area Most level 4 and 5 s go to another area of your ED ( urgent care ) NOT triage away AT THE SAME TIME THE PARALLEL PROCESSING ABILITY
65 Communicating ED Workload To Others The definitions used to differentiate patients with ESI triage are explicit and thus easily understood by clinicians and non-clinicians - such as hospital administrators You are on your way to a meeting where you will discuss ED staffing and the negative effects overcrowding is having on patient safety and staff retention
66 Communicating ED Workload To Others Last evening you had 6 level 2 patients who had to remain for 5 hours in your waiting room: a high risk situation; confused/lethargic/disoriented; or in severe pain or distress This was of great concern to your competent and motivated staff last night, all of whom felt terrible that they could not provide better patient care
67 Communicating ED Workload To Others You can begin to have much more meaningful discussions with your administrators about your ED resourcing needs
68 Physical Plant and Staffing Decisions If nearly 40% of your ED s presentational case mix are 4 s & 5 s do you really need a bigger ED to handle your volume, or do you need a simple re-design of your existing space?
69 Physical Plant, Staffing and Staff Mix Decisions Say 40% of your ED s presentational case mix are 4 s and 5 s. How many/types docs/np s/pa s are you likely to need for that kind of case mix? Particularly if you knew that 65-70% of 4 s and 5 s are boo-boo s boo s (trauma related) Do insurance companies, in general, pay for boo- boo management? Yes, for docs but NP/PA reimbursement is highly state and region specific
70 Multiple Hospital ED Capacity Planning If you have several ED s in your system (country; consulting mix) how might you think about staffing at each site if you had ESI-driven reliable ED case mix data available to you across those ED s? Or, if you are a health planner how could ESI s reliable ED case mix data help you?
71 60% Case Mix by Site % Patients 50% 40% 30% 20% 10% BW FH 17th MH YH UNC LVCC 0% ESI Triage Level
72 Downstream Hospital Readiness See next
73 Presentational Case Mix Data ( can manage the waiting room ) Triage Case Mix Admit Resource ED LOS Level (% total) Rate Intensity (hours) Level (2%) 73% 80% 2.4 Level 2 1,756 (22%) 54% 90% 4.0 Level 3 3,173 (39%) 24% 73% 3.4 Level 4 2,197 (27%) 2% 47% 2.0 Level (10%).003% 14% 1.4 TOTAL 8,063
74 Services Operations Management Concepts, Content, and Tools With ESI case mix data, some that available: Demand analysis and statistical forecasting Capacity to serve planning: optimize staff scheduling (rostering) to predicted demand ED workflow diagramming (ED service unit mapping) and conceptual [static] modeling The Lean (Process Excellence) business improvement method Enhanced discrete event simulation modeling
75 How Can You Get ESI v.4 Triage? Implementation Handbook Training DVD
76
77 Download a pdf version of the Implementation Handbook, fully licensed
78 Request up to (was( 3) now 1 free copy of: The spiral bound Handbook The Everything You Need To Know Training DVD
79 Fixing the Front End: Using ESI Triage v.4 To Optimize Flow David Eitel MD MBA For The ESI Triage Research Team
80 The ED Problem ED Triage -? ESI Triage Background Introduction» History and development Make clear the ESI versions (4); show a couple of major highlights from our work
81 ESI Triage Introduction What it is and how it is implemented What s new in version 4 What you can do with it once it s implemented How to get ESI v.4 from the AHRQ Implementation manual Training video At no cost
82 On Behalf Of The ESI Triage Research Team Dave Eitel Nicki Gilboy Alex Rosenau Paula Tanabe Debbie Travers Rich Wuerz Thank you for the invitation!
83
84 Fixing the Front End: Using ESI Triage v.4 To Optimize Flow David Eitel MD MBA For The ESI Triage Research Team
85 In Memory Of: Richard Wuerz MD Associate Clinical Director Department of Emergency Medicine Brigham and Women s Hospital Harvard Medical School
86 Richard C. Wuerz, MD
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