Electronic Triage comes to the North Bay

Regional Health Centre Emergency Department

Cathy Park RN ,Manager Clinical InformaticsDonna Labreche, RN, Co-ordinator, Emergency DepartmentPam Durocher, RN, BScN, Clinical Nurse Educator, Emergency DepartmentIrene Govis, RN Clinical Informatics Analyst

• 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.

Why ?

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).

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

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

The CTAS Five Levels

Determining the CTAS Level

What are Modifiers?• Provide additional acuity information needed to determine the

CTAS level.

What Did We Do Before Electronic Triage?

• Patients who arrived had a three step Triage process:

1. RN’s 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.

Last to Know

• Hamilton Health Sciences

• Joseph Brant Burlington

• The Scarborough Hospital (came to North Bay Regional Health Centre to share their implementation of the Electronic CTAS)

The End Result

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?

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.

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.

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

Improved Triage Accuracy

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.

What Did we Learn?

More Time to Care