Volume 33 Number 4 JULY/AUGUST 2011 FREE Continuing Nursing Education Introduction The Pat Walker Health Center is an ambulatory care clinic at the University of Arkansas in Fayetteville, Arkansas, which serves the university s students, faculty, and staff. The health center has been accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) since 1987. Health services include a general medical clinic complete with a laboratory, x-ray, allergy/immunization and travel clinic, women s clinic, counseling and psychological clinic, and health promotion and education. The medical staff consists of five full-time and two part-time physicians and three advanced practice nurses. The nursing staff of fifteen is composed of eight registered nurses, four licensed practical nurses, and four certified nursing assistants. The Lyn A. Edington student enrollment was 14,384 in 1997 and 21,405 in fall 2010. This article is the first in a two-part series about the nurse triage program at the health center. Part I will describe the process used to develop a Registered Nurse Triage Program and the immediate impact on patient access and flow. The results of a triage pilot program study will be presented along with a brief consideration of the benefits of the triage program. The program proved successful and the process described here provides ideas and direction to any ambulatory care service that is experiencing patient access and flow issues. Part II will cover the evolution of the triage program and bring the reader up to date. The author will demonstrate the strategies utilized to remain successful, continued on page 6 Page 3 New AAACN Tagline Created at 2011 Annual Conference Page 4 The Power of Storytelling In part 2 of this article, learn how you can collect your own nursing stories and use them to improve your nursing practice. Page 10 For Your Health Page 11 Health Care Reform Ambulatory Nurse Leaders: Developing Opportunities for Patient-Focused Care Navigation Page 12 Telehealth Trials & Triumphs Specialty Nursing Certification: Taking the Next Step Page 13 Educating and Mentoring Nurse Leaders Page 14 From Our Members Page 15 AAACN News Page 16 Start Planning for the Annual Conference Contact hour instructions, objectives, and accreditation information may be found on page 10 The Official Publication of the American Academy of Ambulatory Care Nursing See page 16
College Health Setting continued from page 1 solve new access issues and challenges, and sustain patient and staff satisfaction in the face of record student enrollment, a new facility, and economic factors. The Beginning: Total Chaos In spring 1997, the Pat Walker Health Center (at the time called The University Health Center) experienced an unmanageable walk-in patient volume. Staff morale and patient satisfaction were extremely low. Because of the overwhelming volume, the health center was not able to provide the care that patients expected and deserved. Three factors contributed to the volume: Inefficient intake practices, a staffing shortage, and unrealistic or uninformed use of the service by the patient population. There was no reliable system of tracking or tallying s. Brief or problem types were scheduled every fifteen minutes; physical exams were allotted thirty minutes. The medical providers typically had 22 to 24 patients scheduled per day. It is important to note that the clinic was still using a paper book at that time. The receptionists literally penciled in the s in the book. Cancellations or re-scheduled s were erased. Once erased, those s were gone with no record that they were ever made. The medical and nursing staff did not have access to real-time changes in the schedules. Paper schedules were copied every morning and afternoon and handed out to the nurses and providers. Any changes made after the schedules were copied were not relayed to the nursing or medical staff. Two of the physicians had retired, and it took some time to fill the vacant positions. This shortage left the health center with fewer spots and put a strain on existing medical providers. Inefficient scheduling practices contributed to the walk-in volume. There were a few same-day spots built Figure 1. Flow Chart: Same-Day Appointment Requests Before Triage Pilot Acute spot available Same-day given regardless of acuity Receptionist receives sameday request into the schedule that were to be used for acute problems only. The receptionist filled those spots on a first-call-first-scheduled basis. Once those spots were filled, callers requesting a same-day were given the option to come as a walk-in or make an the next day (see Figure 1). Most chose to come as a walk-in. Not surprisingly, the health center did not have a way to track walk-in patients, either. There was no method of determining what type of problem a walk-in patient would present with or how urgent the problem was, nor did staff know how many walk-ins they saw each day. The nurses screened walk-ins in between scheduled patient s and routed them as best they could, usually squeezing them into an already full schedule. This disrupted the system. The waiting room was often standing-room only. Long wait times contributed to high patient and staff frustration. University of Arkansas students pay a health fee that entitles them to unlimited visits to the health center at no charge. It is not unreasonable for students to think that since they pay the fee, they may as well use the service whenever the need arises. Because many academic instructors required a Offered next-day No same-day available Given the option to come as a walk-in medical excuse for missed classes, this became one of the services students needed and expected. Indeed, students were willing to walk in and wait either to be seen or to receive their medical excuse. This is a common problem in most college health settings and wastes valuable clinician time, according to Corson-Rikert & Christmas (2009). Inappropriate use of health resources, in this case the medical providers, indicated that a change was needed. Phase I: Walk-In Study The physicians decided that to improve patient access and flow as well as pervading feelings of staff and patient frustration, nurse triage needed to be implemented again. The clinic had tried RN triage in the past but didn t find a system that worked. In hindsight, it wasn t triage at all. The triage model consisted of one nurse who was assigned to screen walk-in patients and route them to a medical provider. The nurse was eventually pulled to assist in another area. Therefore, no one was dedicated to assessing the walk-in patients. Before developing a new triage system the first challenge was to devise a system to track walk-in patients. A walk-in study was conducted; during this period, the telephone 6 ViewPoint JULY/AUGUST 2011
Walk-ins week 1 173 Walk-ins week 2 130 Total walk-ins 303 Seen by MD 200 (66%) Seen by NP 71 (24%) Seen by RN 32 (10%) Illness 259 (85%) Injury 44 (15%) intake process remained the same. All walk-in patients were given a walk-in form to complete, shown in Figure 2. The form included demographics, current medications, the reason for the visit, and the onset of symptoms. When appropriate, patients were asked if they would like a nurse to assist in choosing appropriate overthe-counter medications for their symptoms. The form also included a disclaimer about wait times for nonurgent problems and stated that the health center did not give class excuse notes. The medical provider and/or nurse used the form to document the visits, and medical record personnel Figure 2. The Walk-in Form PAT WALKER HEALTH CENTER UNIVERSITY OF ARKANSAS CLINIC RECORD FOR NON-SCHEDULED VISIT PLEASE NOTE: We make every attempt to see patients in a timely manner. Please understand that patients with s and those that were instructed to come in for evaluation are seen first but we must give priority to the very ill or injured. Therefore, patients with minor or chronic medical problems may wish to make an or ask to have a triage nurse call you. If you are here because you missed classes and are no longer ill but need a class excuse, please inform the receptionist. If you are ill or injured, please provide the information below and a triage nurse will evaluate you as quickly as possible. The triage nurse will treat you or refer you to the appropriate medical provider. Name DATE TIME Social Security # or U of A ID Phone Current medications (prescription or over-the-counter) Medication allergies Reason for visit PROGRESS NOTE (to be filled out by clinic staff) Time Bp P T R HT WT LMP Other Allergies S Practitioner s Signature Table 1. Disposition for Study Period collected the forms at the end of each day and recorded the data. After data was reviewed, the form became part of the medical record. During the study period (two weeks), patient wait times ranged from five minutes to 190 minutes. Onset of symptoms or injury ranged from 30 minutes to five months. Using this form, walk-ins were tracked for a two-week period before spring break in March 1997. Table 1 provides data from the study period. The walk-in study provided a clear picture of the extent of the problem. In addition to seeing 22 to 24 scheduled patients each day, the four to five medical providers were also seeing approximately 20 other walk-in patients each day. Phase II: Triage Pilot Program The next step was to develop an effective, efficient, and safe process to manage walk-in patients based on telephone nursing practice standards that were available at that time (American Academy of Ambulatory Care Nursing, 1997; Wheeler & Windt, 1993). A triage team consisting of a nurse practitioner (NP; the director of nursing at the time) and a registered nurse (RN; the author) were selected by the physicians for the triage pilot program. Health center physicians selected nationally recognized written telephone triage protocols (Briggs, 1997) for use as telephone triage guidelines. At that time the clinic was open in the evenings and staffed by registered nurses. If the nurses performed any type of telephone triage, it was informal. The nurses utilized custom standing orders to evaluate after-hours walk-in patients. The walk-in standing orders were symptom based and functioned much the same as telephone triage protocols, and they were written in conjunction with and approved by the medical providers. The orders included history, symptom assessment, physical assessment, lab work, disposition, and self-care instructions. Under these orders, the nurses performed labs such as strep ID and urine dips. An on-call physician was available to the nurses for consultation as needed. The standing orders were often used for definitive treatment of common problems that could be managed by self-care. After-hours walk-in patients were evaluated and usually either treated definitively by the nurse or given an for the next day. Occasionally, the on-call physician was called in for treatments such as laceration repairs. These after-hours standing orders were adapted to use for walk-in patients who presented during regular clinic hours. Under these revised orders, the nurse could defer to a later, recommend over-thecounter medication and self-care advice as the after-hours nurses did, or initiate lab and/or x-ray and refer immediately to a medical provider. All documentation was reviewed and approved by a medical provider. During the pilot, the receptionists were no longer allowed to tell patients to walk in without an. If a patient called requesting a same-day and none were available, the call was referred to the triage RN (see Figure 3). Utilizing the telephone triage protocols, the triage RN determined if WWW.AAACN.ORG 7
Figure 3. Flow Chart: Same-Day Appointment Requests During Triage Pilot Told to walk in at a specified time Caller referred to triage RN Appointment made for a later date Receptionist receives sameday request Self-care advice given (no ) Table 2. Triage Calls During the Triage Pilot Program Total calls the caller should walk in, make an at a later date, or be given advice for self-care. If the patient was given telephone advice only, the record was routed to a physician to review and sign. The medical chief of staff reviewed these records during the triage pilot. Patients who needed a same-day were told to come in at a specified time as a walk-in. Since the nurse practitioner technically did not have an schedule, patients were not given an actual but rather were told that they were being worked in to the schedule to be evaluated by a nurse practitioner. The NP schedule was not available to the front desk as the nurse practitioner was also the nursing Told to walk in ( invited guests ) Caller offered first available at a later date Caller accepts later Given advice or on a later day Week #1 (3/24-3/28) 72 39 (54%) 33 (46%) Week #2 (3/31-4/4) 85 43 (50%) 42 (50%) Week #3 (4/7-4/11) 79 38 (48%) 41 (42%) Week #4 (4/14-4/18) 99 51 (51%) 48 (48%) Week #5 (4/21-4/25) 27 11 (40%) 16 (60%) Week #6 (4/28-5/2) 42 27 (64%) 15 (36%) TOTALS 404 209 (52%) 195 (48%) director and was not always available for patient care. The triage RN spaced these s to allow time to accommodate walk-ins that had not called but needed to be seen. All triage calls were documented in the patient record along with the instructions given to the patient. The calls and disposition were entered into a call log. The clinic now had two different types of walk-in patients: the ones who presented without calling and the ones who had called and were instructed to walk in by the triage RN. The ones who called were referred to as invited guests. All walk-in patients were given the same walk-in intake form that was used during the walk-in study. The triage RN screened the invited guests for the NP and evaluated the other walk-in patients. The invited guests were usually screened before the other walk-ins. Since the triage RN had already obtained a telephone history, vitals were taken and labs were initiated prior to evaluation by the NP as indicated by standing orders. As this new system was being implemented an important safety and quality issue was identified. Serious illnesses or injuries could now be identified immediately instead of potentially languishing in the long wait times or getting lost in the inefficient system. Walk-in patients who had not previously called were evaluated by the triage RN and treated definitively, referred immediately to be seen by the NP, or asked to make an at a later date. Lab work and/or x-rays were initiated if indicated by the standing orders. These patients were advised on the benefits of calling to talk to the triage RN. Medical records of patients treated by the triage RN were routed to a physician (medical chief of staff) to review and sign. The NP consulted with or referred to physicians as necessary when evaluating the walk-in patients. The walk-in visits were entered into a walk-in log sheet. The schedules for the physicians did not change. A walk-in physician was not designated at that time; however, there was a designated on-call physician who was responsible for walk-ins before and after regular hours. Walk-in patients who were referred from triage to a physician were worked into the schedule by the physician s nurse. The pilot program began on 3/24/97 and ended on 5/2/97. The data collected during the pilot was analyzed and the pilot program was evaluated. Discussion Under the old system, conceivably 195 more patients (e.g., those who called and were not given a same-day ) probably would have walked in (see Table 2). The total number of walk-in patients in the triage pilot program (499 in six 8 ViewPoint JULY/AUGUST 2011
250 200 150 100 50 0 Table 3. Walk-ins Evaluated During the Triage Pilot Program # Seen by MD # Seen by NP Week 1 Week 3 Week 5 # Seen by RN # Given appt Figure 4. Total Triage Contacts During the Six-Week Triage Pilot Totals Week #1 40 (37%) 31 (30%) 36 (33%) 0 107 Week #2 69 (69%) 1(NP gone) 29 (29%) 0 99 Week #3 50 (50%) 33 (33%) 13 (13%0 3 (3%) 99 Week #4 30 (37%) 40 (38%) 19 (18%) 7 (7%) 96 Week #5 17 (33%) 8 (15%) 15 (29%) 11 (13%) 51 Week #6 17 (36%) 9 (19%) 13 (27%) 8 (18%) 47 TOTALS 223 (45%) 122 (24%) 125 (24%) 29 (7%) 499 weeks; see Table 3) decreased by more than 50% from the walk-in study (303 in two weeks; see Table 1, page 7). This is most likely due to the implementation of changes at intake. Of the patients who called requesting same-day care and were routed to triage, 48% were given telephone advice for their symptoms or given an at a later date. This data is notable for two reasons: it was consistent with standards at the time (Lazarus, 1995; Stirewalt, Linn, Godoy, Knoola, & Linn, 1982) and that percentage remained steady in later years, as you will see in Part II of this series. The number of walk-in patients seen by physicians during the pilot program decreased from 66% to 45%. The number of patients seen by the nurse practitioner stayed the same, because she was not available 10 of the 30 days of the program due Walk-ins Phone Calls Triage Totals to travel. The number of walk-ins seen by the RNs increased from 10% to 24%. Seven percent of the walk-in patients were given s for a later date (see Table 1, page 7, and Table 3, above). By week five of the pilot program, the patients understood the change that the health center was functioning mainly as an clinic. Walk-in visits and requests for sameday, non-acute s decreased by 50% (see Figure 4). Conclusion The new triage system relieved some of the pressure on the front desk, physicians, and nurses. Walk-ins were spread out, making them easier to manage, and patient wait times were reduced. Patients with serious illnesses or injuries were quickly identified and received immediate assistance. Of the 499 patients who walked in without an during the pilot program, 299 (59%) had not called first to request an and 209 (41%) had called and were instructed to come in at a specific time. The triage program was deemed a huge success and it was recommended that it should be instituted as a formal program. Five key lessons that could apply to all ambulatory care clinics have been demonstrated: A clear understanding and description of the problem is needed to establish a baseline and measure change and success. Capitalize on existing processes and resources such as RN triage and standing orders when possible. Flexibility is necessary to accommodate unanticipated challenges such as emergencies, walk-ins and staff shortages. Patients must be provided with information about proper utilization and the benefits of the services available to them. Safe and appropriate patient care is the bottom line and must guide all decision making. Recognizing the immediate benefits of the changes that were implemented motivated us to look at other ways to improve the system. Stay tuned for Part II, which will provide information on educating the college health center population, meeting their health needs, ensuring their satisfaction, and measuring the successes of the improved and expanded process. Lyn A. Edington, RNC, is Nurse Manager, Pat Walker Health Center, University of Arkansas, Fayetteville, AR. She may be contacted at edington@uark.edu References American Academy of Ambulatory Care Nursing. (1997). Telephone nursing practice administration and practice standards. Pitman, NJ: Author. Briggs, J. (1997). Telephone triage protocols for nurses. New York: Lippincott. Corson-Rikert, J., & Christmas, W.A. (2009). The medical excuse game revisited. Journal of American College Health, 57(5), 561 564. continued on next page WWW.AAACN.ORG 9
Lazarus, I. (1995, October) Medical call centers: An effective demand management strategy for providers and plans. Managed Health Care, 22-26. Stirewalt, C.F., Linn, M.W., Godoy, G., Knoola, F., & Linn, B.S., (1982). Effectiveness of an ambulatory care telephone service in reducing drop-in visits and improving satisfaction with care. Medical Care, 20(7), 739-748. Wheeler, S.Q., & Windt, J. (1993). Telephone triage theory, practice & protocol development. Albany, New York: Delmar. Instructions for Continuing Nursing Education Contact Hours Improving Access, Patient Flow, and Nurse Triage in a College Health Setting Deadline for Submission: August 31, 2013 To Obtain CNE Contact Hours 1. For those wishing to obtain CNE contact hours, you must read the article and complete the evaluation online in the AAACN Online Library. ViewPoint contact hours are free to AAACN members. Visit www.prolibraries.com/aaacn and log in using your AAACN email address and password. (Use the same log in and password for your AAACN Web site account and Online Library account.) Click "ViewPoint Articles" in the left hand navigation bar. Read the ViewPoint article of your choosing, complete the online evaluation for that article, and print your CNE certificate immediately. 2. Upon completion of the evaluation, a certificate for 1.0 contact hour may be printed. Fees AAACN members: FREE Regular price: $20 Objectives The purpose of this CNE article is to inform ambulatory care nurses about the development and evolution of a nurse triage system at a busy student health center. After reading the information presented in this article you will be able to: 1. Identify the factors that contributed to a high walk-in patient volume at a student health center. 2. Discuss the steps taken to implement a nurse triage pilot program. 3. Describe five ways to apply the benefits of a nurse triage program to all ambulatory care clinics. The author has not disclosed any affiliation or financial interest in relation to this educational activity. This educational activity has been co-provided by AAACN and Anthony J. Jannetti, Inc. Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses' Credentialing Center's Commission on Accreditation (ANCC-COA). AAACN is an approved provider of continuing nursing education by the California Board of Registered Nursing, provider number CEP5366. California licenses must retain this document for four years. This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE- BC, Education Director. Reprinted from ViewPoint, 2011, Volume 33, Number 4, pp. 1, 6-10. Reprinted with permission of the publisher, the American Academy of Ambulatory Care Nursing (AAACN), East Holly Avenue, Box 56, Pitman, NJ 08071-0056; 856-256-2300; FAX 856-589-7463; Email: aaacn@ajj.com; Web site: www.aaacn.org 10 ViewPoint JULY/AUGUST 2011