Implementing the use of Emergency Severity Index Triage tool in Urgent Care
Urgent care centers significantly contribute to the management of chronic illnesses or episodic diseases. Patient with these illnesses receive healthcare services upon visiting the facilities without booking appointments. The Urgent Care Association (2019) defined urgent care centers as outpatient facilities that offer outpatient healthcare services to individuals with chronic illnesses, injuries, and other healthcare problems that requires immediate medical attention. With increasing demand for management of chronic illnesses, urgent care centers are gaining popularity in the healthcare system. Advanced practice providers, specializing in various discipline provide quality, safe, and efficient to patient presented to these medical facilities, preventing their health condition from deteriorating. The choice to choose the Urgent Care Clinic (UCC) over the emergency department (ED) is dependent on many factors. Inconvenience office hours for doctors, overcrowding and long waiting times in the emergency department and long waiting times for outpatient appointments have resulted in patients using urgent care to solve their immediate medical needs. The patient volume of urgent care has increased from 20 patients daily to over 100 patients (Memmel & Spalsbury, 2017). These factors are extremely significant and should be considered when providing healthcare services to patients presented to urgent care centers. Nonetheless, these factors don’t matter to patients who don’t understand about UCC’s resources and ability. For this reason, healthcare staff working in the UCC are requires to distinguish between an acute and non-acute patient and prioritize provision of healthcare services to acute patients, preventing deterioration of their conditions or death (Snodgrass, 2020).
The implementation of the (ESI) triage tool will propose a quality improvement project at the urgent care (Gilboy, Tanabe, Travers, & Rosenau, 2020). Despite having a significant impact on the quality of care and heath outcome, ESI has not been successfully implemented in our UCC, compromising the quality of patient care, which leads to adverse health outcomes. This project aims at assessing the effectiveness of the ESI tool in improving patients’ triage based on acuity. Additionally, the project will assess the effectiveness of triage protocol in lowering door-to-provider time, walkouts, and emergent waiting room events.
Patients who visit healthcare facilities seeking treatment for exacerbations of chronic conditions or episodic illnesses such as asthma without scheduled appointment receive healthcare services from Urgent Care Centers (UCC) or Emergency Departments (EDs) (McNeeley, 2012; Weinick, Burns, & Mehrotra, 2010). The acuity of patients who walk into UCCs varies. In most cases, patients visiting UCC present life-threatening or critical symptoms (Siegfried, Jacobs, & Olympia, 2019). Thus, healthcare providers conduct an efficient patient screening process to identify patient’s condition and respond promptly, preventing further health complications or death. (i.e., initiate treatment, stabilize the patient, discharge, or transfer to ED). Health outcomes of patients seeking healthcare services from the UCC significantly depend on the time that patients wait before being seen by an APN or a doctor.
Most urgent care clinics are open twenty- four hours seven days a week that provide quality healthcare. Recently, accessibility and utilization of urgent care services has increased significantly, resulting in positive health outcomes (Krause et al. 2018). There are some health conditions are not appropriate to be managed in an urgent care setting. In some cases, patients seeking healthcare services from UCC are unaware of their health status, necessitating appropriate assessment to understand patient’s health condition. Lack of triage tools creates an improper assessment for licensed nurses who may not have previous training with identifying higher acuity patients. Triage is the screening process that marks the beginning of the UCC throughput (patient flow through the department) and treatment experience for a patient. Triage involves a designated registered nurse (RN) who performs a focused assessment of a patient’s condition to determine the priority of need for treatment or medical intervention (Falconer et al., 2018). When a patient is not triaged timely and accurately, or the essential triage information is not gathered and documented, the medical intervention and disposition of the patient can be delayed.
The ESI is a five-level triage scale that facilitates patients’ prioritization based on the urgency of their medical conditions (Gilboy et al., 2020). Triage nurses utilize the ESI tool to determine the resources required for disposition. The ESI has two basic foundations. It aims to sort patients by levels of urgency and streamline patient flow (Gilboy et al., 2020). This tool allows for rapid identification of patients with urgent medical needs. It enables quick sorting of patients in constrained resource settings. Patients are sorted into five acuity groups from most urgent to least urgent. This allows triage nurses to project operation and resource needs (Gilboy et al., 2020). Although there is no standardized triage process for use in UCCs (i.e., triage documentation, acuity tool, assessment practices, etc.), research indicates that UCCs function similarly to EDs (UCAOA, 2018; Sanders, 2000). Therefore, effective standard triage mechanisms already in place in EDs could be beneficial in UCC settings.
The University Urgent Care is one of major departments in the healthcare organization. It provides healthcare services to patients who visit the facility, seeking immediate medical attention following exacerbation of chronic illnesses or injuries. Particularly, during the COVID-19 pandemic, the urgent care has been receiving an overwhelming number of patients. Some of these patients are not in a stable health condition to provide health history needed during diagnosis and treatment. Thus, healthcare staff working in the urgent care department should screening patients thoroughly upon arrival. Assessment results guide healthcare providers during diagnosis and treatment. However, assessment of patients seeking healthcare services from the urgent care unit is compromised by lack of the Emergency Severity Index (ESI) triage tool.
A SWOT analysis is strategy that is used assess internal and external factor’s affecting organization’s performance and likelihood of successful implementation of a new project. A SWOT analysis of organization’s internal and external environmental factors that are likely to influence the implementation of ESI triage tool in the urgent care unit. Internal environment consisted of strengths and weaknesses. Organization’s internal strengths include support from the director and nurse manager, supportive and collaborative nurses, understanding work demands of current staff work demands, and the availability of highly-competent and dedicate healthcare staff. These strength are more than weaknesses, increasing likelihood of successful implementation of the ESI triage tool. Staffs should be educated on how to use of the ESI triage tool to enable them triage and assess patients based on acuity, resulting in positive health outcomes. The urgent care activated a triage protocol when the facility opened in 2013. The triage protocol has since been non-existent. There have been several office managers since the clinic open who have since discontinue the process because the information was not clear and concise. The current triage process in urgent care is based on first-come, first-served. Consequently, leading to delays of care, adverse outcomes, increasing waiting time, walkouts, and emergent waiting room events. This lack of triaging based on acuity has the potential for adverse outcomes. Between 2008 and 2015, there was an increase of 119% in patient visits to UCCs (Siegfried et al., 2019). As the UCCs continue to see an increase in patient visits per year and the symptom acuity of walk-in patients continue to vary, it is essential to ensure that there is a standard process for prioritizing care (Alkon, 2018).
Evidence from June 2021 to February 2022 gap analysis revealed 61,388 patients were serviced at UCC. Those that are of higher acuity include chest pain 1,628, shortness of breath 625, abdominal pain 1,559, weakness 51, sepsis 9, deep vein thrombus 7, NSTEMI 4 and osteomyelitis 10. In the UC, we are servicing a higher acuity of patients that are not being seen based on acuity. The lack of triaging based on acuity has the potential for adverse outcomes. The consequences of inadequate or lack of triage protocol implementation will impact the quality of healthcare and safety. Weaknesses are no triage rooms for Health Insurance Portability and Accountability Act (HIPAA) privacy, few staff members, and lack of formal training for healthcare providers. Opportunities include reduced wait times for high acuity patients, earlier referrals to ED, prevention of waiting room emergencies or events, and highly-efficient patient care. Possible threats are responsibilities placed on RNs and the CMAs that could potentially cause stress and anxiety, and lack of knowledge of the public of the UCC’s patient care abilities. The stakeholders are welcoming this opportunity to advance quality patient care in this urgent care setting.
The urgent care does not require a prior appointment and services patients on a walk-in basis. Patients requiring higher level of care, once identified, would need to be transported via ambulance to the University hospital. The University Urgent Care serves an average of 80 patients daily and 150 patients daily during flu season. Staffing consists of 2 secretaries, 1 RN, 2-3 CMAs, 1 physician, 2-3 APPs a shift. The intake process at the urgent care begins when the patient checks-in with a service representative. The service representatives collect patient registration information, including the patient’s chief complaint (or symptom). There is no clear concise protocol for patients that check in with “red flags symptoms.”
The protocol currently used in urgent care to room patients is often that of first-come, first-served. The structure does not enable the use of prioritization based on patient acuity. An inquiry based on urgent care patients triaged with ESI tool compared to no ESI with decrease in wait time based on acuity.
Aims and Objectives
The overarching aims of this project were to implement and evaluate the ESI triage tool to accurately assess patient acuity, to reduce door-to-provider time based on the current practice, and to reduce adverse events resulting in transfers to a higher level of care. The objectives involves enhancing staffs’ accuracy and consistency in using the ESI triage tool to assess patients in the urgent care setting. A one week training program was scheduled to equip the role group, including CMAs, licensed nurses, and the providers with knowledge needed for effective use of the ESI triage tool. Thus, training would enable staff to assess and triage, understanding the patient acuity and urgency for healthcare services. Patients in need of urgent care should be given priority to prevent deterioration of their health or death.
Review of Literature
Electronic search was conducted to obtain relevant evidence. Key words, including triage, emergency severity index, urgent care clinics/centers, emergency department, licensed vocational nurse, registered nurse, emergency department wait times, and ESI training were used to guide the search process. The literature search was conducted on several nursing databases, including PubMed, EBSCOhost, CINAHL, and Google Scholar databases. These databases were preferred since they provide highly-reliable and credible evidence. Twenty articles were selected from the returned list. Articles were reviewed to assess if they met the inclusion criteria or relevance to the subject matter. Four articles were selected based on UCCs and ambulatory care clinics. Five articles were included based on ED wait times. Lastly, twenty articles were selected based on relevance to the project’s topic.
Research has been conducted to address provider wait times in the emergent urgent care clinics and outpatient patient care clinic. Research findings indicated that using a triage system enables healthcare providers to prioritize patients based on their acuity. Acute patients are given priority over non-acute patients. Thus, waiting time for acute patients is relatively shorter reducing the risk of further complications or death. On the other, although triage aims at reducing waiting time for non-acute patients, the time they patients take before receiving healthcare services significantly depends on the number of acute patients seeking treatment in the urgent care unit. Additionally, implementing triage in urgent care unit improves specialty provider visits, improving the quality of care. On the contrary, failure to implement the triage tool in the UCC results in unnecessary transfers to EDs resulting in long wait time in the emergency department. Staff in the acute care tends to transfer patients to the emergence department due to the lack of knowledge, skills, and competence needed to assess patients properly (Zitek, Tanone, Ramos, Fama, & Ali, 2018). Literature review indicated various themes attributed to the implementation of triage protocols such as significance of triage in the urgent care unit; reducing door-to-provider times; preventing adverse events in the waiting area; improving patient throughout; and eradicating potential barriers to implementation of the triage tool.
Implementation of ESI Triage Tool in Delivery of Urgent Care in UCC
The goal of a quality improvement project by (Snodgrass, 2020) is to teach licensed nurses how to use the ESI triage tool to assess patient acuity and reduce wait times in the urgent care setting quickly and accurately. The UCC care team, including LVNs and RNs, will collaborate based on the patient’s triage score for decision-making purposes. The ESI tool’s ability to accurately triage patients for the most appropriate level of care to improve patient outcomes is supported by this study. All levels of nursing training can make use of the acuity scale. The advanced practice nurses adopted a simple but effective triage tool at this UCC, which is suitable for all levels of nursing education.
It was found that using PCRs, an evidence-based triage system called the ESI could be successfully implemented and evaluated in an urgent care setting (Burgess, 2017). According to the study’s results, the educational course had a positive statistical impact. Essential to effective triage in an emergency room is providing information for ESI. Patients who need to be evaluated by a doctor immediately and possibly referred to another level of care have been identified using PCRs, thanks to the implementation of the Triage method in urgent care settings.
Use of ESI Triage Tool in ED
For this study, Sarvari et al. (2020) surveyed emergency department patients to see if implementing and using the emergency severity index (ESI) would reduce wait times. For the Mann-Whitney test, it was found to have a positive effect on the average time intervals for providing health services and the total length of stay in an emergency department. ESI is better for emergency personnel like training nurses because of its positive impact on patient wait times following the implementation of the ESI triage system.
Admission triage for intensive care units (ICUs) is standard and frequently involves highly subjective decisions that could lead to inappropriate ICU admissions. Ramos et al. (2019) evaluated a decision-aid tool for ICU triage in this study to see if it affected ICU admission. They found that ICU admissions were reduced after the use of an ICU triage decision-aid tool was implemented.
Wechkunanukul et al. (2016) conducted a review to see if there is a correlation between ethnicity and delays in seeking medical attention for chest pain in CALD populations. There was no time limit on the search for relevant studies that were published or unpublished in English. All the investigations took place in October of 2014. Two independent reviewers used the Joanna Briggs Institute’s standardized data extraction tool to extract data from the included articles. A narrative summary was created from the gathered information. It has been found that patients from ethnic minorities take longer to seek medical attention for chest pain than those from the majority population. There should be a focus on these populations regarding health campaigns and promotions.
There is a higher hospitalization rate for cancer-related ED visits than for non-cancer ED visits. Many of these expensive hospital admissions could be avoided, but there are not enough cancer-specific resources in urgent care clinics and EDs to meet the demands of this diverse population. Research recommendations from workshop participants to reduce the risk of oncologic complications, improve the management of these complications, and enhance coordination of care Shelburne et al. (2022). Participants in the workshop emphasized the importance of breaking down silos between medical specialties to improve research and patient care. To better integrate emergency medicine into oncology care and research, respondents stated a gap between emergency medicine and oncology departments that could be bridged more effectively.
Same Day Emergency Care and Urgent Care Model Triage
According to Atkin et al., (2022), a review that defines SDEC and describes the differences in service across the United States was published in 2012. Evidence of clinical impact, tools to screen for SDEC in patients, and current gaps in our knowledge about service deployment are all covered in this paper. According to their findings, SDEC is currently the highest priority in NHS acute care services to reduce hospital admissions, resulting in inpatient service demands for a select group of patients. Many questions remain unanswered, however. An evaluation of clinical benefit is required to grasp how systems can be implemented effectively and thoroughly. It is unclear whether standardization across healthcare settings or pathways tailored to local demographics and healthcare needs is beneficial.
A study by Devriendt et al. (2018) examined the impact of the URGENT care model on the rate of unplanned ED readmissions. Secondary outcomes include a higher hospitalization rate; more extended stays in emergency departments (EDs), more extended hospital stays, more intensive treatment, functional decline, and death. This study builds on previous research with local adaptations and focuses on the transition of care for older patients in the ED. Even though these innovative care models have been tested in other settings, there is no conclusive evidence that they work in the ED. Conclusions: Older patients in the emergency department could benefit from the URGENT care model, which has been thoroughly researched and tested.
ED triage literature has proliferated, and this growth has been accompanied by a wide range of study designs, methodologies, and outcomes. An effort to synthesize the existing ED triage articles using a framework that allows for contrast and benchmarking all over triage systems about clinical outcomes, reliability, and patient outcomes was the goal of Hinson et al (2019). We discovered that many ED patients who died or became critically ill after their initial encounter was not designated as high acuity at triage. Triage performance can be improved by enhancing interrater reliability and triage accuracy.
The Clinical Frailty Scale was validated by Kaeppeli et al. (2020), who examined and determined the scale’s independent predictive validity for ICU admission, 30-day mortality, and hospitalization. The Clinical Frailty Scale was used to determine the occurrence of frailty in the ED. According to their findings, fraud is a valid and reliable diagnostic tool in the emergency department. It helped ED doctors make informed choices about whom to treat and how to treat them.
ESI Triage Implementation
Villa et al. (2018) conducted a study to determine if adapting the ESI scale into a computerized algorithm in electronic health records (EHRs) shortened the ED triage time. It was a pre-post experimental study done in the ED of an urban tertiary hospital. The intervention involved integrating the ESI algorithm into a commercial EHR. The study results revealed that the median triage interval for patients was 5.9 minutes before the intervention and 2.8 minutes after the intervention (Villa et al., 2018). Patients with high acuity levels were the ones who benefitted more from this intervention. There was a decrease from 6.8 minutes to 2.9 minutes (Villa et al., 2018). The triage levels improved when one nurse was present and for patients who came to the ED department by ambulance. The median triage level for ambulatory patients decreased from 6 minutes to three minutes, while ambulance patients decreased from 5.9 to 2.3 minutes (Villa et al., 2018). The integration of the ESI algorithm decreased the triage time by an average of 3.4 minutes while creating an 11% improvement in the proportion of patients with high acuity triaged within 15 minutes at the ED.
AlSerkal et al. (2020) conducted a study to evaluate the accuracy of the ESI tool and its linkage with patient factors. Five hundred seventy-six thousand one hundred fifty-four patients visited the emergency department during the study period, with 54.4% male. There was a significant increase in length of hospitalization with increasing severity of illness. There was a positive correlation between the accuracy of triage and illness severity (AlSerkal et al., 2020). Patients aged 11-20 years had the highest chances of accurate triage acuity (AlSerkal et al., 2020). There was no linkage between the nationality of the patient and triage accuracy. This showed that was no clinician bias when using the ESI tool. Correct assigning of acuity level results in prompt treatment of patients, while incorrect assignment can result in unnecessary consumption of healthcare resources and increased wait time for patients (AlSerkal et al., 2020).
Ghafarypour-Jahrom et al. (2018) carried out a prospective study with the aim of determining whether the Emergency Severity Index (ESI) as a tool measure what it is claimed to measure. For this they assessed its reliability, validity, specificity, and sensitivity. The study took place in a population sample of children aged below 14 years in the emergency department. The researchers found that the ESI is indeed valid and has good reliability.
Hinson et al. (2018) studied the frequency of errors in triage using the ESI in Brazil in an emergency department. The single-center retrospective cohort study compared initial ESI scores and the final one entered by the treating physician. The researchers used the nonparametric tool of Chi-square to draw inferences. They found that there are often many patients in the ED that are either under-triaged or over-triaged. Levin et al. (2018) studied the efficacy of the electronic triage system in the US. They found that the e-triage accurately classifies ESI level III patients but recommended further studies on its validity. Mirhaghi (2016) on his part wrote an opinion piece about the ESI and gave various valid factual points. However, since this is not a study with a methodology, its value as evidence for evidence-based practice (EBP) change is very limited.
Mistry et al. (2018a) and Mistry et al. (2018b) are two studies that looked at the perceptions of nurses concerning the ESI (2018a) and the reliability and accuracy of the ES in triaging patients in the emergency department (2018b). The former found that there was a lot of subjectivity in triaging using the ESI by nurses. The latter study on its part found that variability in the scores was quite high and hence the reliability of the tool was low. These findings are in stark contrast to those by Ghafarypour-Jahrom et al. (2018) as indicated above. Finally, Silva et al. (2017) looked at the accuracy of risk classification just like Ghafarypour-Jahrom et al. (2018) and Mistry et al. (2018b). They found that nurses’ accuracy in predicting risk using the ESI tool was low.
There is a gap in research given the limited use of ESI or any standard triage protocol in UCCs. There are limited evidenced based universal triage protocol associated with UCCs or stand along clinics. There is one documented quasi experimental study that the results have shown that the Emergency Severity Index system can contribute to a decrease in the negative crowding outcomes in primary health care centers. The limited use of triage in this UCC setting has directed this quality improvement project.
This project will use Kurt Lewin’s theory of planned change as a theoretical model. The theory of planned change was postulated in 1947. The purpose of the change model is to help in understanding why change occurs and how it can be done in a seamless way. The model also illustrates how people react when dealing with change in their lives (Hussain et al., 2018). For the theory to be applicable, change must occur. The change theory has three major concepts, namely: driving forces, restraining forces, and equilibrium. Driving forces facilitate change by pushing in the direction that causes it to happen and causing a shift in the equilibrium towards change. Restraining forces counter driving forces and hinder change by driving patients in the opposite direction and causing a shift in the equilibrium that opposes change. Equilibrium is a state that occurs when driving forces are equal to restraining forces. When an equilibrium state is achieved, no change occurs.
The theory of change is applicable to this project because it seeks to introduce a new change regarding patient triage. The theory will help in identifying the change focus (ESI triage tool utilization) and communicating with relevant stakeholders, which creates a sense of security and trust for all involved in the proposed change. The theory is relevant in the change implementation process by helping all those involved to sustain change and resolve any challenges through further education (Rosenbaum et al., 2018). The theory will also help in evaluating the effectiveness of the new educational tool once the change is completed, a summary of problems encountered, and the successes realized.
The theory of change has three phases of change: unfreezing, change, and refreezing. The unfreezing phase involves the willingness to make a change and learn new ways. This project assumes that the nurses will be receptive and willing to learn by conducting a needs assessment to identify the existing problems (Rosenbaum et al., 2018). The change phase entails making an actual change until the desired state is achieved. The project will introduce a new triage process and educational tool to help the staff participants identify and implement a strategy to move in the desired direction. This tool is expected to enhance nurses’ ways of thinking and processing information to minimize adverse events and create awareness to high acuity patients being evalutated. In the refreezing phase, the participants are expected to have reinforced learning, which will be evident in the way nurses perform their duties and the utilization of ESI triage tool knowledge. In addition, nurses’ mindsets will be in a new state where they have accepted the change and are comfortable with the new state.
Evidence supports the importance of triage education, training, and process standardization (Hitchcock et al., 2014). Obtaining the correct assessment information to determine patient urgency is a critical step in ensuring patient safety (Malmstom et al., 2017). This quality improvement project is aimed at recognizing the importance of triage; reducing door-to-provider times; lowering the risk of adverse events in the waiting area; improving patient throughout; and eliminating perceived barriers to implementation, such as lack of staff, poor communication, low level of education and skills, and adverse or near-adverse events. The design is to assess the effectiveness of implementing an Emergency Severity Index triage system in urgent care center. PDSA (Plan-Do-Study-Act) was utilized in introducing change to the organization (Aggarwal, 2020). The Plan do study act is an iterative, four-stage problem solving model used for improving a process or carrying out change.
The first stage (plan) begins with first identifying a problem and creating an intervention that corrects the problem. The second stage (Do) is to start the implementation of the intervention that has been created to address the problem. The third stage (Study) involves analyzing the data collected and continuous reinforcement to ensure the plan is working. The final stage is (Act), which is to actively work to improve or sustain the intervention (Taylor et al., 2022). The PDSA model has been utilized in several healthcare settings and is considered a reliable and valid method for implementation of an intervention (Institute for Healthcare Improvement, 2018; Langley et al, 2009; Taylor et al., 2022). The project was implemented at a time the UCC was seeing high volumes. The project was piloted with receptionist, RNs, all providers at the UCC. Patient demographic information along with triage check in times along with time to provider was collected before the ESI educational intervention. The data collected showed the current wait times and acuity levels at the facility. This data was compared with the data at the end of the change implementation process. The change was expected to be implemented over an eight-week period.
Pre- and post-study design was used in this project. This study design was preferred since it allows researchers to measures the outcome before and after the implementation of a particular intervention. The effectiveness of the intervention in addressing a particular issue or improving a process is determined by comparing outcomes before and after implementing the proposed intervention. During the project, the waiting time for urgent care patients and providers wait time were measured before and after implementing the ESI triage tool.
Model for Improvement
The first step in the Deming PDSA the purpose of the project. The quality improvement of this project is aimed at recognizing the importance of triage; reducing door-to-provider times; lowering the risk of adverse events in the waiting area; improving patient throughout; and eliminating perceived barriers to implementation, such as lack of staff, poor communication, low level of education and skills, and adverse or near-adverse events. The nurse participants were given an eight-week period to accurately use the ESI tool. After eight weeks, analysis of ESI triage tool will be compared to previous wait times, as well as emergent interventions. The analysis collected pre and post intervention will be compared to evaluate the effectiveness of the ESI tool.
In the planning stage of the project, a complete review and analysis of the current triage process along with regulations that apply to the UCC policies for triage were performed. There was an internal review conducted to assess the current UCC screening practices. The identified gap in practice from this review along with inconsistent triage times, extended wait times, and the ability to identify acuity of patient due to triage training deficits were discussed with the key stakeholders of this project. The stakeholders included department leadership, the education department, the compliance department, and physician leaders. After stakeholders reviewed evidence and suggestions for modification to the current triage process, approval for the final change process was obtained from the department administration along with physicians and leaders.
The second stage of the PDSA cycle was to analyze data collected from the pre-intervention period and implement the ESI education program. Data was analyzed with assistance of the University’s Clinical and Translational Science (CCTS) team. This included a review of the current triage times from check in, triage times to provider, as well as high acuity diagnosis. This step was an important part the project, it highlighted the gap at the UCC which created awareness of the problem that allowed an easy buy in from the stakeholders. An email to stakeholders was then emailed, which highlighted the gap as well as the purpose of the ESI triage. The email also includes a rollout plan for educated that staff on the ESI triage tool. ESI education was held as an in-service program to prevent interference with normal care processes. Education was done over two weekday shifts to accommodate nurses from all alternate shifts and to reinforce the learning process.
The third step in the PDSA was to monitor the effect of the implementation to ensure the objectives were being met. This entails giving the participants a chance to practice implementation of the ESI tool. To evaluate the effectiveness of the triage protocols, each ESI triage tool was audited daily by the PI. Analysis of the screening was assessed to ensure each patient was being screened, the appropriate diagnosis was assigned along with ESI scoring, check in times along with triage times were being documented. The data obtained from this analysis were to identify any possible gaps that need further training.
The last step in the PDSA cycle was to implement the ESI tool and reinforce its use. The nurse participants were given an eight-week period to accurately use the ESI tool. After eight weeks, analysis of ESI triage tool will be compared to previous wait times, as well as emergent interventions. The analysis collected pre and post intervention will be compared to evaluate the effectiveness of the ESI tool. During this stage it was also important to evaluate how the clinic will be able to maintain triage assessment and documentation competency moving forward.
The University Urgent Care serves close to 80 patients daily, 150 patients daily during flu season. The physical layout of the urgent care consists of a waiting room, a reception desk (facing the lobby), a separate desk area adjacent to the reception desk for the triage nurse, 11 exam rooms. Staffing consists of 2 secretaries, 1 RN, 2-3 CMAs, 1 physician, 2-3 APPs a shift. The PI and head nurse were excluded from this project, making the sample size 17 nurses.
The ESI triage tool was implemented at the UCC and the participants included were all patients who were receiving urgent care. The RNs, CMAs, Physicians, Physician Assistants and Nurse Practitioners, all have varying backgrounds and skill experience related to triage. It was essential for training prior to implementation of the ESI tool, to ensure every staff member grasp the aspect and the importance of triaging by acuity. This training helped strengthen the efficiency and quality when utilizing the ESI triage tool for screening. Office managers and charge nurses were included in the training just so they were aware of the content and performance expectations of each staff member. Lab technicians as well as administrative assistances were excluded from the project.
A flyer was developed and placed in the nurse break room, providing information on the implementation of the project and the required educational session that would take place and the dates: May 11, 2022, and May 18, 2022. The two educational sessions occurred on two weekday shifts to ensure coverage of most day shift staff. Light refreshments were provided, educational materials and badge cards were also distributed to all staff who attended.
The DNP project does not require a consent. It is a quality improvement change process that obtain data by secondary analysis. Secondary analysis refers to the use of existing research data to find answers to a question that was different from the original work. Research does not always involve collection of data from the participants. If the data has no identifying information, then it does not require a full review by the ethical board. The use of secondary data does not subject the patient to any harm or adverse outcomes. Full disclosure of the quality improvement project was shared with all participants including registered nurses, physicians, CMAs, along all affiliated staff members in a staff meeting and through email communication and posted flyers in the department. Triage training was arranged at times that were convenient for participants.
Tools and Instruments
The ESI is a five-level triage scale that facilitates patients’ prioritization based on the urgency of their medical conditions (Gilboy et al., 2020). Triage nurses utilize the ESI tool to determine the resources required for emergency department (ED) disposition. The ESI has two basic foundations. It aims to sort patients by levels of urgency and streamline patient flow (Gilboy et al., 2020). The ESI tool has been revised three times, and currently, the fourth version of the tool is being used. The ESI is a unique tool that requires triage nurses to foresee the required resources such as procedures and diagnostic tests (Gilboy et al., 2020). The ESI tool has several benefits. It allows for rapid identification of patients with urgent medical needs. ESI enables quick sorting of patients in constrained resource settings. Patients are sorted into five acuity groups from most urgent to least urgent. This allows triage nurses to project operation and resource needs (Gilboy et al., 2020). The rapid sorting of patients using the ESI tool improves patients flow in the emergency department (Gilboy et al., 2020). ESI tool allows for the discrimination of patients who should not be seen in the emergency department but could be efficiently seen in an urgent care facility (Gilboy et al., 2020). This tool facilitates effective communication of patient acuity. The ESI offers emergency departments a reliable and valid triage system (Gilboy et al., 2020).
Data Analysis Tools and Procedures
Descriptive Statistics was utilized to provide the summary about the collected data. Graphics and analytics were formed to describe what the data showed. With the utilization of descriptive statistics, we were able to break down lots of data into a simpler summary. Univariate analysis was also utilized in this project to examine the distribution, central tendency as well as dispersion. The mean, median and range was also analyzed to compute the standard deviation and differences of the mean. All analyses were conducted using Microsoft Excel (2016).
The timeline for this DNP project spanned the final three semesters of the academic program (See Appendix J).
The planning phase consisted of identifying an area of clinical or healthcare concern that was shared with faculty advisory for approval. Once approved a PICOT question was created and submitted. A clinical analysis as well as a literature review was performed to ensure that there was evidence base information relevant to the project. Also, during the planning phase, a DNP chair was assigned who serve on my committee who have expertise relevant to the proposed project. Once project title and proposal were approved by DNP chair and faculty, final PERC review was completed and approved on April 26, 2022. IRB application was then submitted to the University on May 5, 2022, and was approved May 9, 2022.
Project implementation commenced on May 11, 2022, and continued until July 5, 2022. Before the implementation of the project an informational letter was sent to the office manager to send to staff to create awareness of the new quality improvement process. Staff education sessions occurred on May 11th and May 18th over a 8 hour period.
Data review and analysis began on July 8, 2022 and continued until July 18, 2022. Interpretation of outcomes began after data analysis in July 2022.
The presentation of the DNP project results occurred in the Fall of 2022.
Budget & Resources
This accrued no additional costs during the education sessions or while the implementation project was being commenced. The DNP student volunteered time while the education was being delivered. The hired statistician was paid $330 for their expense. The ESI triage tool required no equipment. The expense for the paper being utilized to print the ESI tool, was $10 dollar ink and $20 for paper. There was no cost to the organization. For staff participating in education session pizza was bought for a total cost of $35.
Upon IRB approval from the University and the facility, the PI was then able to collect pre data over a 6-month period from June 2021 until February 2022 which included: check in, triage times, time to provider and discharge time. All information was obtained with the assistance from The Center of Clinical Translation Science (CCTS). There was a thorough examination of the information obtained and the data collected reflected the current wait times and triage acuity levels at the UCC. An informational letter as well a power point was created to present to the UCC stakeholders (physician leadership and management including department supervisors). After reviewing information letter (See Appendix C), approval was given by the stakeholders to initiate the new triage tool.
Phase 2. The problem of not having a sufficient triage protocol was identified. Buy in from stakeholder were accomplish in this stage and another email was created to inform staff of the new change process
The project supports the effectiveness of the education and the implementation of ESI triage tool in the UCC. Post implementation proved that the effectiveness of the ESI tool improves patient outcome by triaging the patients with an accurate acuity level for the most appropriate level of care. The project also showed that the ESI triage screening tool can be utilized by all levels of healthcare. The stakeholder was able to acknowledge the need for patient acuity within the facility. While utilizing the ESI triage tool, the UCC improve their wait times according to acuity. By implementing this quality improvement project using the ESI triage tool, this UCC was able to prove that triage by acuity was beneficial to all parties involved.
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