Goal: Improve door to bed, length of stay and patient satisfaction by reducing delays in ED triage and registration.

Innovation: When a patient arrives in the emergency department (ED), there is a need to get both registration information and clinical information about the patient’s condition. St. Francis set out to integrate these two processes, as well as to standardize how long it took a nurse to triage a patient.

Result: Since the implementation of this practice, St. Francis decreased their length of stay from 253 minutes in 2008 to 173 minutes in 2009. Also, the rate of patients who left without being seen decreased from 3.86% to 2.62%, and decreased staff turnover – all during a period of increased ED volume.

Institution: St. Francis Hospital-Indianapolis 1600 Albany Street Beech Grove IN 46107 P: (317) 865.5234

From the expert:

Combining our registration and triage work was a very important factor in achieving the improvement that we wanted to see. Our wait times were decreased significantly just by doing that and it has been getting better ever since. And now, with the Workstation on Wheels, our times are going to keep decreasing because we are better utilizing the resources and technology at our disposal.

Patty Heffner Nurse Manager

Profile: Location: Indianapolis, IN Number of emergency department visits annually: approximately 60,000 Number of beds: 230 Ownership: private, St. Francis Hospitals & Health Centers Teaching status: No St. Francis Hospital-Indianapolis is a 230-bed community hospital with 60,000 ED visits annually. Clinical areas affected:

  • Emergency department
  • Registration department

Staff involved:

  • Nurses
  • Registration staff
  • ED administrative staff
  • IT/technical support departments

Timeline: From start to finish, including the development, planning, rollout, acquisition of equipment and full implementation, the process took about eight months.

Contact: Patty Heffner Nurse Manager Patricia.heffner@ssfhs.org P: (317) 865-5234

Innovation Implementation: When patients arrive in the ED, there is a need to collect both registration information about the patient and clinical triage information about their condition. At most hospitals, unfortunately, these processes are usually handled by separate staff and at separate locations in hospitals, requiring patients to move from one wait to the next and oftentimes experiencing the delays in care and treatment that are the bane of EDs everywhere.

The result is often low patient satisfaction scores, poorer door-to-bed times and increase left without being seen rates. Looking for ways to improve this situation, the ED team at St. Francis hospital examined the practices at their sister hospital which had better door-to-bed times and saw something that caught their eye.

While there were few practice differences between the institutions, the team did recognize that the registrar and triage nurse at that hospital sat at the same desk. This seemingly simple difference appeared to improve operations, resulting in less wasted time for collecting the patient information. Seeing this as a potential strategy for improvement, the team set out to address it by better integrating the patient registration and clinical intake processes.

The first and most obvious step to doing this was to combine the two physical areas, putting the ED triage nurse and lead registrar in the same workstation. This was an easy shift and only involved moving their work areas closer together. Then the team took the integration further, identifying four questions that overlapped between what both the triage nurse and registrar needed, and had them change practices to work together to answer the questions.

Most recently, St. Francis even acquired a workstation on wheels (WOW), which allows the registrar to complete the registration process in patient rooms, further cutting down on the time the patient has to spend in the waiting room.

Advice and lessons learned:

  1. Other departments need to be aware of crowding. One of the most welcome outcomes from this project was how those in other departments became aware of the problem of ED crowding, and how they might contribute to it, and what they can do to help alleviate it.
  2. Be relentless about data collection. This particular process is very data-driven—customer satisfaction ratings, patient wait times, etc.—and as such, vigilant data collection is required.
  3. Be patient. People, of course, don’t generally love change. Stick with it, expect some push back, but don’t take staff errors as stubborn resistance.

Cost/benefit estimate: St. Francis nets about $1,100 on a patient, and gets about 62,000 visitors to the ED each year. By decreasing their left without being seen rate by over a percentage point, they are getting about 770 people through their ER that they would not otherwise see. That comes out to about $840,000 more per year with minimal investment primarily consisting of reallocating staff workspace and resources. Tools to Download:

  • Charted Door-to-Bed Process Flow Chart