By Dusti Browning, MSN, RN, NE-BC
The convergence of COVID-19, respiratory syncytial virus (RSV), and influenza—healthcare’s “tripledemic”—highlighted the weaknesses of the nation’s healthcare system to triage large numbers of patients quickly and efficiently in the emergency department (ED). It also underscored opportunities to optimize patient flow in and out of a hospital system. Now, as tripledemic concerns linger and some hospitals still struggle to bring in patients from other hospitals, healthcare leaders must rethink their approach to patient transfer services to protect care access and quality.
During November 2022, hospitals in states such as Maryland, Massachusetts, and North Carolina were forced to set up triaging tents in their parking lots, postpone elective surgeries, or impose visitor restrictions owing to the high numbers of patients showing up in their EDs. In December, patients at one Oregon health system had to wait for more than two days to be transferred to other facilities for higher levels of care. In effect, the situation felt like 2020 again.
Yet challenges with patient triaging and transfer aren’t limited to periods of widespread illnesses. That’s one reason why innovative health systems are leaning into nurse-driven solutions for patient transfer and triage. These solutions relieve pressure for overstretched healthcare teams and reduce costs while improving quality of care and patient satisfaction.
The imperative for a better approach
A December 2022 American Hospital Association fact sheet illustrates the extent to which workforce shortages, higher patient acuity, and increased lengths of stay have reduced ED capacity. The challenge is compounded by a rise in cases of COVID-19, RSV, and the flu—a scenario some experts predict could get worse following holiday gatherings and a return to school after winter break.
But besides buckling under high patient volumes, many hospitals suffer from disorganized and inefficient procedures for patient transfer and discharge. When ED volumes are high and processes for transferring patients to an inpatient unit or another facility are inconsistent or unclear, patients may spend hours or even days boarding in the ED. Today, the ED boarding situation has reached crisis levels, prompting the American College of Emergency Physicians (ACEP) and other groups to urge the Biden administration to lead the charge for near-term and long-term solutions.
“Boarding doesn’t just impact those waiting to receive care elsewhere,” the ACEP and other key stakeholders stated in a letter to the President. “When ED beds are already filled with boarded patients, other patients are decompensating and, in some cases, dying while in ED waiting rooms during their tenth, eleventh, or even twelfth hour of waiting to be seen by a physician.”
Centralizing and standardizing procedures for patient triage—ensuring the right patients are seen in the right setting, including the ED, at the right time—and patient transfer can improve patient flow and quality of care. With concrete procedures, staff can capture the information needed for physicians to make timely and informed decisions on a patient’s appropriate setting and level of care. Clarifying triage and transfer procedures also saves time at important points in the patient journey—from ED evaluation to admission—improving access to care, care delivery, and health outcomes.
New models for improving ED flow
How can health systems adjust their approach to patient triage and transfer to promote safer care and a better care experience, including in the ED? Emerging models of care concentrate on improving patient flow by strengthening care decision-making at the start of the encounter. They also look for ways to centralize and standardize patient flow processes as well as use data and dedicated resources to make informed decisions and reduce pressure on staff.
Here are three approaches that are making a difference for patient safety and quality of care:
- A 24/7 dedicated nurse-first triage line. Staffed by nurses, this solution helps patients determine the right setting for care before they arrive in the ED. A triage line prevents unnecessary ED visits while giving ED staff the information they need to direct the right resources to the right patients at the right time. More and more, employers and health plans are relying on nurse-first triage to reduce healthcare costs and strengthen quality of care by supporting optimal utilization of care resources, including urgent care and the ED. Patients and family members gain peace of mind knowing a registered nurse has assessed the patient’s condition and recommended the most appropriate care.
For instance, using standards such as the evidence-based Schmitt-Thompson protocols, the nurse will ask the patient for the location, severity, and duration of their back pain. Depending on the answers, the nurse will recommend an appropriate course of action, such as calling 911, going to the ED, or managing the symptoms at home with ice and/or over-the-counter medication. ED physicians and clinicians, meanwhile, gain time to focus on existing patients and operations. This approach also minimizes after-hours on-call responsibilities for specialty physicians.
Medical Mutual, one of Ohio’s largest health insurance companies, implemented a 24/7 nurse-first triage line. During its first year, the resource helped redirect half of callers who had intended to go to the ED. Member call hold times and hang-up rates also fell significantly, while member satisfaction increased. Over time, the plan’s ED avoidance rate jumped to nearly 90%.
- Nurse-driven patient transfer centers. Coordinating patient transfers is complex, and it’s made even more difficult by inefficient processes and lack of time for staff to fix transfer problems. Nurse-driven patient transfer centers—whether established by health systems or run with a specialized support partner—give EDs the dedicated expertise to navigate the complexities of patient transfer, internally and to outside facilities, more effectively. This model significantly reduces ED boarding time while decreasing the impact of intrahospital transfers on nursing workload.
For three health systems that rely on this model, nurse-driven patient transfer centers have increased inbound patient transfers by more than 30%. For EDs, this raises the potential for teams to treat more people in need, enhancing access to care while protecting patient safety.
- Data-driven process improvement. Many health systems don’t have a process for monitoring patient transfers. This limits their ability to determine why lengthy ED boarding times are occurring and work toward a solution. It also decreases their potential to avoid out-migration of patients, where appropriate. Closely examining the transfer process from start to finish, whether with the help of the health system’s quality assurance department or in collaboration with an outside partner, will reduce ED boarding and help to optimize patient transfer. Key data points to review include the time from ED intake to physician acceptance and, from there, to bed placement or discharge. Continuous evaluation of metrics can allow health systems to enhance care access and quality while reducing care costs and strain on staff.
Prepare for this time and next time
The tripledemic tested health systems’ ability to triage and transfer large numbers of incoming patients, at a time when many of these systems were already struggling to do so. By examining opportunities to strengthen their approach to patient triage and transfer in the ED, organizations can more effectively deal with patient surges, now and in the future.
Dusti Browning, MSN, RN, NE-BC, is vice president of growth and client solutions at Conduit Health Partners.