Electronic Triage comes to the North Bay Regional Health Centre Emergency Department

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Electronic Triage comes to the North Bay Regional
Health Centre Emergency Department

• Cathy Park RN ,Manager Clinical Informatics
• Donna Labreche, RN, Co-ordinator, Emergency
  Department
• Pam Durocher, RN, BScN, Clinical Nurse Educator,
  Emergency Department
• Irene Govis, RN Clinical Informatics Analyst

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Why ?

• The ED was the next step in our journey towards
  an electronic record and the department was ready
  and willing to go next. 
• Senior Team and Advisory Committee endorsed the
  project.
• To improve Triage Scoring Accuracy and
  Standardizing Assessments.
• By tracking our metrics pre, during and post
  implementation we would see improvement
  statistically.

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Why was it Important for Nursing?

• It was an opportunity to re-educate the staff on
  Triage.
• To improve documentation and ensure triage
  assessments were conducted in a standard and
  consistent way.
• To have readily available tools at their
  fingertips ie. (Trackers, CTAS Modifiers).
• To have all patient information in one spot for
  the multidisciplinary team to access (PCI).

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Stakeholders

• ED Staff
• Clinical Informatics
• Manager, ED
• Clinical Co-ordinator, ED
• Director Medicine Care Center
• Clinical Educator, ED
• ED Physician
• Clerical Staff, ED

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What is the Canadian Triage and Acuity Scale
(CTAS) ?

• A sorting process utilizing critical thinking
  in which an experienced RN assesses patients
  quickly upon their arrival at an emergency
  setting
• 1. assess and determine severity of
  presenting problems
• 2. process patients into a triage category
• 3. determine access to appropriate treatment
• 4. effectively and efficiently assign
  appropriate human health resources
  
• 
  NENA Position Statement
• 
  A-1-4, 2002

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The CTAS Five Levels
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Determining the CTAS Level
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What are Modifiers?

• Provide additional acuity information needed to
  determine the CTAS level.

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What Did We Do Before Electronic Triage?

• Patients who arrived had a three step Triage
  process
• 1. RNs completed a Triage sticker with all
  the relevant information.
• 2. Registered by the Triage Clerk.
• 3. Once the chart was printed an RN would
  complete the assessment in a Triage Assessment
  Room or Patient Care Area.

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Last to Know
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• Hamilton Health Sciences
• Joseph Brant Burlington
• The Scarborough Hospital (came to North Bay
  Regional Health Centre to share their
  implementation of the Electronic CTAS)

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The End Result
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Next Steps Before Implementation

• We needed to create processes, policies and
  tools that the staff could reference prior to
  implementation. These
• included
• Standards of Care/ Documentation for the ED -
  Unit Standards
• ED Electronic Triage/ Documentation Policy
• ED Patient Flow Algorithms
• EDM User Manual
• Various cheat sheets
• What to do for downtime?

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Educating the Staff

• A core group of ED Nurses were chosen to be Super
  users. They were given extra training days to
  practice the screens.
• All ED staff were brought in for hands on
  computer training, power points presentations
  and given case studies to work thru the screens.
• Staff had the opportunity to ask questions.
• Triage trained staff were recertified.

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Our Metrics

• The Dart Tool provides daily data regarding our
  P4R metrics and visual management of the ED.
• Several trackers were built to manage patient
  flow in the department (Registration Required,
  Assessment Required and Reassessment for Waiting
  Room Patients.
• PIA times have improved through visual management
  and organized flow processes.
• In April of 2015 we were ranked 10th out of 74
  hospitals in the province as a high performing
  ED.
• We are currently ranked 13th in the province.

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Benefits to Electronic Triage

• Patient assessments were based on CEDIS
  complaints which saved time during the patient
  interview.
• Improved documentation and standardized
  assessments.
• New ED staff were able to complete a thorough
  assessment without Triage training.
• CTAS levels improved with the mandatory use of
  Modifiers.
• Identified an increase in acuity of patients
  which resulted in increased funding for physician
  hours in a 24 hour period
• 46.26 hours in June 2012
• 48.26 hours in September
  2013
• 50.28 hours in December
  2013
• 54.64 hours in July 2014
• 60.45 hours in May 2015

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Improved Triage Accuracy
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Challenges

• Recent change in management along with the
  implementation of a high scale project.
• Ongoing staff morale issues.
• Multiple challenges with Meditech Platform.
• Frontline staff felt platform was not user
  friendly.
• Lack of Physician engagement
• Buy in from front line staff.
• Understanding of processes from nursing and IT
  perspectives.

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What Did we Learn?
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More Time to Care