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Impact of Rapid Entry and Accelerated Care at Triage on Reducing Emergency Department Patient Wait Times, Length of Stay, and Rate of Leaving Without Being Seen
Correspondence outcomes of patients who did not wait. Valid and reliable data on such parameters are limited, particularly when large cohort studies with high follow-up rates are rare. Don Liew, MBBS The Royal Melbourne Hospital Melbourne, Victoria, Australia. doi:10.1016/j.annemergmed.2005.08.035 1. Chan TC, Killeen JP, Kelly D, et al. Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, length of stay, and rate of leaving without being seen. Ann Emerg Med. 2005;46:491-497. 2. Womack JP, Jones DT. Lean Thinking: Banish Waste and Create Wealth in Your Corporation: Part 1: Lean Principles. London, United Kingdom:Simon and Schuster;2003. 3. Fernandes CM, Daya MR, Barry S, et al. Emergency department patients who leave without seeing a physician: the Toronto Hospital experience. Ann Emerg Med. 1994;24:1092-1096. 4. Goodacre S, Webster A. Who waits longest in the emergency department and who leaves without being seen? Emerg Med J. 2005;22:93-96. 5. Australasian College for Emergency Medicine. Policy document: the Australasian Triage Scale. Available at: http//www.acem.org.au/ open/documents/triage.htm. Accessed August 5, 2005.
Impact of Rapid Entry and Accelerated Care at Triage on Reducing Emergency Department Patient Wait Times, Length of Stay, and Rate of Leaving Without Being Seen In reply: We thank Dr. Liew for his interest in our recent article and appreciate his commentary.1 We completely agree that many steps in the patient care process in the emergency department (ED) are not “value-adding,” impede patient flow, and ultimately result in patient frustration and dissatisfaction. Our goal with the Rapid Entry and Accelerated Care at Triage (REACT) process was to eliminate many of the “non–valueadding” processes we identified that hindered patient entry and initial care in our ED. Dr. Liew comments that our work assumed that clerical processes are a “major constraint” and “very time consuming,” and that “medical staff are highly efficient or in abundance.” Although single clerical tasks themselves may require little time, we identified numerous duplicative and redundant processes that impeded patient entry into our ED. Moreover, because these tasks were required before patient care and evaluation could be initiated, patients were subjected to multiple sequential queues, resulting in greater delay (particularly at times of increased patient census) than might be expected for the actual clerical tasks involved. Our goal with REACT was to eliminate these tasks as a requirement for initiating patient care, to consolidate duplicative and redundant processes, and to discourage staff acceptance of patient queuing as a routine part of entry into our ED. Volume , . : March
As an academic ED with faculty and resident staffing, we acknowledged in our study that our findings may not be applicable to other settings, including Dr. Liew’s ED where “poor access to a physician” causes prolonged waiting times. We do not believe that our staff is “in abundance,” and, in fact, when we designed the REACT process we limited physiciandirected care at triage only to times when all ED beds were occupied. Our goal with this project was to accelerate the process between the patient’s arrival to the ED and when they received medical care. Prolonged wait times have been identified as a major barrier to accessing care based on patient perceptions.2 Although we used various informatics and communication technologies to accomplish this task, we believe the change in our workflow can be duplicated elsewhere by using other tools and approaches. We agree with Dr. Liew’s suggestion to focus on the outcomes of patients who did receive care at triage. We are in the process of analyzing our data on this issue and hope to report findings shortly. We also agree that more research is needed on patients who leave the ED before being seen by a physician, including investigations as to the reasons why these patients leave before medical care and the potential impact on outcome that may have occurred as a result. Addressing this issue is important not only as “a necessary risk management strategy” but also from the standpoint of quality of patient care and community public health. Theodore C. Chan, MD James P. Killeen, MD Donna Kelly, RN David A. Guss, MD Department of Emergency Medicine University of California, San Diego, Medical Center San Diego, CA doi:10.1016/j.annemergmed.2005.09.021 1. Chan TC, Killeen JP, Kelly D, et al. Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, length of stay, and rate of left without being seen. Ann Emerg Med. 2005;46:491-497. 2. Kennedy J, Rhodes K, Walls CA, et al. Access to emergency care: restricted by long waiting times and cost and coverage concerns. Ann Emerg Med. 2004;43:567-573.
Gastroduodenal Corrosive Injury After Oral Zinc Oxide To the Editor: A 39-year-old man presented to the emergency department with nausea, vomiting, and abdominal pain 6 hours after ingesting 150 g of 10% zinc oxide lotion. On physical examination, he was conscious, and vital signs remained stationary (blood pressure 132/72 mm Hg, pulse 72 beats/min, respiration 20 breaths/min, temperature 37.6°C/99.7°F). The Annals of Emergency Medicine 295
Impact of Rapid Entry and Accelerated Care at Triage on Reducing Emergency Department Patient Wait Times, Length of Stay, and Rate of Leaving Without Being Seen In reply: We thank Dr. Liew for his interest in our recent article and appreciate his commentary.1 We completely agree that many steps in the patient care process in the emergency department (ED) are not “value-adding,” impede patient flow, and ultimately result in patient frustration and dissatisfaction. Our goal with the Rapid Entry and Accelerated Care at Triage (REACT) process was to eliminate many of the “non–valueadding” processes we identified that hindered patient entry and initial care in our ED. Dr. Liew comments that our work assumed that clerical processes are a “major constraint” and “very time consuming,” and that “medical staff are highly efficient or in abundance.” Although single clerical tasks themselves may require little time, we identified numerous duplicative and redundant processes that impeded patient entry into our ED. Moreover, because these tasks were required before patient care and evaluation could be initiated, patients were subjected to multiple sequential queues, resulting in greater delay (particularly at times of increased patient census) than might be expected for the actual clerical tasks involved. Our goal with REACT was to eliminate these tasks as a requirement for initiating patient care, to consolidate duplicative and redundant processes, and to discourage staff acceptance of patient queuing as a routine part of entry into our ED. Volume , . : March
As an academic ED with faculty and resident staffing, we acknowledged in our study that our findings may not be applicable to other settings, including Dr. Liew’s ED where “poor access to a physician” causes prolonged waiting times. We do not believe that our staff is “in abundance,” and, in fact, when we designed the REACT process we limited physiciandirected care at triage only to times when all ED beds were occupied. Our goal with this project was to accelerate the process between the patient’s arrival to the ED and when they received medical care. Prolonged wait times have been identified as a major barrier to accessing care based on patient perceptions.2 Although we used various informatics and communication technologies to accomplish this task, we believe the change in our workflow can be duplicated elsewhere by using other tools and approaches. We agree with Dr. Liew’s suggestion to focus on the outcomes of patients who did receive care at triage. We are in the process of analyzing our data on this issue and hope to report findings shortly. We also agree that more research is needed on patients who leave the ED before being seen by a physician, including investigations as to the reasons why these patients leave before medical care and the potential impact on outcome that may have occurred as a result. Addressing this issue is important not only as “a necessary risk management strategy” but also from the standpoint of quality of patient care and community public health. Theodore C. Chan, MD James P. Killeen, MD Donna Kelly, RN David A. Guss, MD Department of Emergency Medicine University of California, San Diego, Medical Center San Diego, CA doi:10.1016/j.annemergmed.2005.09.021 1. Chan TC, Killeen JP, Kelly D, et al. Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, length of stay, and rate of left without being seen. Ann Emerg Med. 2005;46:491-497. 2. Kennedy J, Rhodes K, Walls CA, et al. Access to emergency care: restricted by long waiting times and cost and coverage concerns. Ann Emerg Med. 2004;43:567-573.
Gastroduodenal Corrosive Injury After Oral Zinc Oxide To the Editor: A 39-year-old man presented to the emergency department with nausea, vomiting, and abdominal pain 6 hours after ingesting 150 g of 10% zinc oxide lotion. On physical examination, he was conscious, and vital signs remained stationary (blood pressure 132/72 mm Hg, pulse 72 beats/min, respiration 20 breaths/min, temperature 37.6°C/99.7°F). The Annals of Emergency Medicine 295