Thoughts on alternative ED staffing model

[USCDiver]

I have been tossing around this staffing model in my head for a few years and wanted to get the thoughts from the collective wisdom of SDN EM.

As I'm sure is true at many of your sites, there is a push to have a Provider in Triage or some other sort of first look process to help throughput and decrease LWBS.

So what I envision is a system where there is a Doc up front in triage (as opposed to APP) and more APPs in the back. Additionally there are Doctor(s) in the back seeing EMS/High acuity patients.
The Doc in Triage sees all walk-ins as they come through triage and, in conjunction with the Triage nurse, helps determine acuity, orders a workup (if indicated) and jots down a basic note. This provider is NOT expected to do any dispos. Some patients would be shuttled through a Fast Track area to see an APP. The rest are sent to the back to see an APP or Doc as appropriate for their acuity (sometimes strokes and MIs come in the front door too).

Pros:
Every patient eventually seen by an APP is a shared visit (improved collections).
All patients are getting an appropriate workup ordered early (APPs in Triage tend to over-order in my experience).
The doc in triage has limited responsibility for documenting, no dispos, consult calls, admissions, etc.
If the APP has a question about workup or disposition, the Doc has already seen the patient.
Higher patient satisfaction seeing a doctor early in their visit.
Doc(s) in the back can work without as many interruptions by APPs (APPs may end up seeing some lower acuity EMS patients)

Cons:
Need a space where you can do a real (albeit cursory) physical exam (like abdominal exam to determine CT vs US)
Might be difficult to keep up with Triage RN all day long in a busy ED
The triage shift might be less appealing for less efficient docs (scribes could help tremendously)
RVU generation might be low for that shift (or higher depending on how you calculate shared visits)
The Doc(s) in the back are only seeing high acuity patients all day long (might be a feature or a bug depending on the provider).

What am I missing? Has anyone tried this before?

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[theWUbear]

we do this, and are envision, so this must be an established model. doc in triage, sends home reallly easy stuff, sends low acuity needing workup/lacs/etc to NPs, sends moderate to high acuity to main ED staffed by second doc & residents.

this is a level II trauma center, moderative volume

 

[Groove]

We tried this one time at a busy trauma center I used to work at. We called them "screening shifts". Not all the docs were crazy about doing them, but a few of us figured out they could be big RVU generators. We would put a doc in triage and also give them a few rooms to put people that only needed a quick lac repair or I&D or set of labs, etc.. We would screen, put in orders, dump the pt into the main ED if they were complicated and treat/street the rest of them. It worked really well but they were grueling shifts where you might see 40 pt/8 hr shift.

Interestingly, the RVUs were actually very good during this shift because you could dispo so many yourself. Having the few rooms nearby to place simple pt's is key with access to nurse and tech. We did this a few months and then stopped....I'm not sure why.

 

[NYEMMED]

Been there, done that.

It sounds great, but doesn’t work as well.

The APPs are then dispositioning a patient you touched= high liability for you

The APP still orders the same over work up later, now costing more time

Hard and also high liability to “share visit” a patient you really had little involvement with.

It does work well when it’s sent back to physicians unless It’s a urgent care complaint. But if your plan is to replace a physician shift to a PIT shift than nope

 

[USCDiver]

Been there, done that.

It sounds great, but doesn’t work as well.

The APPs are then dispositioning a patient you touched= high liability for you

The APP still orders the same over work up later, now costing more time

Hard and also high liability to “share visit” a patient you really had little involvement with.

It does work well when it’s sent back to physicians unless It’s a urgent care complaint. But if your plan is to replace a physician shift to a PIT shift than nope

That's interesting. Is there more liability for a Shared Visit than there is for a visit where the APP put your name on the chart but you had no involvement at all?

 

[NYEMMED]

That's interesting. Is there more liability for a Shared Visit than there is for a visit where the APP put your name on the chart but you had no involvement at all?

There are varying percentages of liability.

If you never saw the patient or were never consulted on the patient but you signed the chart, you are indeed liable, but the percentage is much lower. (Ive seen 15% for "lack of supervision")

If you actually saw and touched the patient, Your share in the liability is higher...

 

[Hercules]

I have been tossing around this staffing model in my head for a few years and wanted to get the thoughts from the collective wisdom of SDN EM.

As I'm sure is true at many of your sites, there is a push to have a Provider in Triage or some other sort of first look process to help throughput and decrease LWBS.

So what I envision is a system where there is a Doc up front in triage (as opposed to APP) and more APPs in the back. Additionally there are Doctor(s) in the back seeing EMS/High acuity patients.
The Doc in Triage sees all walk-ins as they come through triage and, in conjunction with the Triage nurse, helps determine acuity, orders a workup (if indicated) and jots down a basic note. This provider is NOT expected to do any dispos. Some patients would be shuttled through a Fast Track area to see an APP. The rest are sent to the back to see an APP or Doc as appropriate for their acuity (sometimes strokes and MIs come in the front door too).

Pros:
Every patient eventually seen by an APP is a shared visit (improved collections).
All patients are getting an appropriate workup ordered early (APPs in Triage tend to over-order in my experience).
The doc in triage has limited responsibility for documenting, no dispos, consult calls, admissions, etc.
If the APP has a question about workup or disposition, the Doc has already seen the patient.
Higher patient satisfaction seeing a doctor early in their visit.
Doc(s) in the back can work without as many interruptions by APPs (APPs may end up seeing some lower acuity EMS patients)

Cons:
Need a space where you can do a real (albeit cursory) physical exam (like abdominal exam to determine CT vs US)
Might be difficult to keep up with Triage RN all day long in a busy ED
The triage shift might be less appealing for less efficient docs (scribes could help tremendously)
RVU generation might be low for that shift (or higher depending on how you calculate shared visits)
The Doc(s) in the back are only seeing high acuity patients all day long (might be a feature or a bug depending on the provider).

What am I missing? Has anyone tried this before?

Why do you need anyone (doctor or midlevel) in triage? Phrased better: what problem are you trying to solve by doing this? This is usually done by CMGs to massage the numbers and decrease door to doc times with no meaningful decrease in LOS. If your goal is to quickly dispo patients who need minimal resources utilized than you don’t need a PIT; you need vertical beds that can quickly be turned and burned by your existing staff. If your goal is to get workups going earlier in the patient visit then empower your nursing staff to use standing orders on standard complaints, so you can decrease that bottleneck. I dont need a midlevel or a doctor involved to know that the 75YO with a cardiac history and chest pain needs cardiac labs, a CXR, and an EKG cooking as soon as they hit the door.

 

[GeneralVeers]

I hate people in triage doing "screening exams" and ordering a bunch of crap. If it's a PA, or one of my more nervous colleagues, every patient gets the kitchen sink ordered, when often reassurance and a script is all they need.

One system we used that worked well on the front end, was put a doctor and 2 PAs up front. The doctor screens all the incoming charts and assigns the low acuity ones for the PAs to see and dispo while the doctor picks up all the weak/dizzy old ladies. The nice thing about this is that we were literally all in the same room, and I could hear every PA interview and visually see every patient while they were getting triaged. That made discussions about every patient with the PA super easy, and was likely safer overall.

 

[thegenius]

OP, in your model how does the doc in triage get paid?

 

[thegenius]

PA's over order stuff, even docs do to for that matter. Sometimes all you need to do is a quick exam, like an abdominal exam, and for that you need to lay them down to do it properly. But sometimes you can't do that in triage. It literally takes too long.

I was accused of being slow in triage, but my door-to-doc time was 1 minute slower than the average while up there. Average was like 13 minutes, mine was 14.

The other problem with triage is it's easy to dismiss symptoms, or downplay them. People come gallivantly walking in with abd pain, with normal vitals, and it's easy to say "that is nothing..." until you exam in them and they have RLQ tenderness and have an appy.

I think triage kind of sucks, but if docs want to get paid a lot, and hospitals want their numbers then we are going to have it. It's just poorly fixing a broken device that ends up breaking later. We are not making health care better by having triage up front.

 

[Brigade4Radiant]

There are varying percentages of liability.

If you never saw the patient or were never consulted on the patient but you signed the chart, you are indeed liable, but the percentage is much lower. (Ive seen 15% for "lack of supervision")

If you actually saw and touched the patient, Your share in the liability is higher...

What does this even mean? If there’s a bad outcome and depending on the state you can be held liable. What is this percentage liability matter in a lawsuit?

Also one can argue that because you didn’t see him when you were in a supervisory roll means that you are liable

 

[GeneralVeers]

What does this even mean? If there’s a bad outcome and depending on the state you can be held liable. What is this percentage liability matter in a lawsuit?

Also one can argue that because you didn’t see him when you were in a supervisory roll means that you are liable

If you are the physician signing the chart, you are 100% liable even if you had no contact with the patient.

 

[Brigade4Radiant]

If you are the physician signing the chart, you are 100% liable even if you had no contact with the patient.

Yes exactly! You attest to their chart so I don’t see how liability can be reduced. I mean you are the MD on the chart.

If you’re using MPs and PAs the physician is going to be liable for them so I don’t see why you have to double check their work and waste time unless it’s a questionable patient. In fact you should probably attest to their notes so you can bill higher.

 

[ShockIndex]

“Provider” in Triage encapsulates just about everything wrong with emergency medicine and is perhaps the single greatest moral hazard to the speciality. Provider is in quotes because their is very little light between the physician, PA, and NP order monkeys.

Most obviously, this construct embodies our willingness to sacrifice quality on the alter of money. More subtlety, it represents our pathetic willingness to lick the boot of hospital administrators by perpetuating the very maladaptive systems that make EM a failed paradigm in America.

I dream of the day when CMS cracks down on this crap as the embodiment of fraud, waste, and abuse.

 

[emergentmd]

That would be the worse EM job to have. Cut my wrist why don't you. Seriously. I get to sit in triage, see EVERY patient, start orders with the waiting room full, pissed off loud/smelly patients. After a Long shift of seeing EVERY patient, i get to look back with APCs/other docs changing my orders and questioning my evals.

No thank you. I prefer to be in the back and go take breaks when I feel like it rather than looking down the barrel of a 2 hr waiting room.

 

[Arcan57]

I hate people in triage doing "screening exams" and ordering a bunch of crap. If it's a PA, or one of my more nervous colleagues, every patient gets the kitchen sink ordered, when often reassurance and a script is all they need.

One system we used that worked well on the front end, was put a doctor and 2 PAs up front. The doctor screens all the incoming charts and assigns the low acuity ones for the PAs to see and dispo while the doctor picks up all the weak/dizzy old ladies. The nice thing about this is that we were literally all in the same room, and I could hear every PA interview and visually see every patient while they were getting triaged. That made discussions about every patient with the PA super easy, and was likely safer overall.

We ran that system at my first job except the 2nd PA was in a dispo area. Could burn through 60+ patients/10 hrs as the doc. Efficient as all hell but an exhausting shift.

 

[bravotwozero]

The ED I work at does not have the kind of volume to justify doing this sort of thing, even before the lockdown. Had a MLP who normally works at the mothership downtown (where they are perpetually in a holding pattern) started ‘screening patients’ without letting me know initially and led to a lot of confusion as I though she was picking up the patient. Was told promptly to cut it out.

If you’ve got enough beds to put patients in at any given time, there’s simply no need for doing stuff like this. I realize though the vast majority of EDs are not like ours.


Sent from my iPhone using Tapatalk

 

[GeneralVeers]

We ran that system at my first job except the 2nd PA was in a dispo area. Could burn through 60+ patients/10 hrs as the doc. Efficient as all hell but an exhausting shift.

We would trade off. One doc would be assigned to triage for 4 hours, then move to the back to finish workups and pick up a few ambulances and the next doc on would start in triage. Seemed to work pretty well.

 

[ShockIndex]

One last point - any students headed into EM needs to make sure they understand the role of provider-in-triage at any program they plan to rank. It is a big negative if a majority of patients seen by the residents have tests ordered by an attending or mid-level in triage. A lot of big name programs have started doing this within the past 5 years and the real impact on their graduate product has yet to be realized. The fact that this educational threat is not being tracked for program accreditation is evidence that GME is a decade behind the times.

 

[turkeyjerky]

One last point - any students headed into EM needs to make sure they understand the role of provider-in-triage at any program they plan to rank. It is a big negative if a majority of patients seen by the residents have tests ordered by an attending or mid-level in triage. A lot of big name programs have started doing this within the past 5 years and the real impact on their graduate product has yet to be realized. The fact that this educational threat is not being tracked for program accreditation is evidence that GME is a decade behind the times.

Agreed. My program had aggressive nurse-initiated protocols, so most anyone who came through the WR already had labs or plain films done, which is a negative as well but pretty much necessary for flow. But they never had advanced imaging ordered already. Would definitely be a negative to already have the whole w/u already ordered by the time you see the patient, especially given the tendency to over-order in triage.

 

[docB]

We tried this several years ago when the metric of the month was time to provider. We were trying to run out to the waiting room every time anyone checked in do lower the metric time. We'd go running out, say "Hi, I'm docB! I'm sorry for the wait. Thank you for choosing this hospital. We knew you were coming we just did know your name. Insert other scripting here." Then go throw in some orders. That met the metric. And it had some good effects. It reduced LAT to almost nil. The orders were pretty good. There weren't too many liability issues and most people were pretty good at telling sick from not sick.

The things that really scuttled it were billing related. Our billing company can't (won't) split RVUs for a patient between 2 docs. So the rule is that whoever does the dispo gets the RVUs. So the triage doc really doesn't earn any RVUs. So you have to pay them some per hour rate out of the general pay pool. That tends to cost more than it's worth from an RVU generation standpoint. If the triage guy does keep some of the patients the regular shift guys felt like they were loosing RVUs that they were entitled to. There was so much arguing and dissatisfaction about it that it died. We figured out some other ways to meet the metric and administration saw some new shiny thing and traipsed off after that dragon us along.

I think it can work. It's just a question of do you really need it for a metric or some other specific goal and can your financial system allow for it.

 

[jw3600]

One last point - any students headed into EM needs to make sure they understand the role of provider-in-triage at any program they plan to rank. It is a big negative if a majority of patients seen by the residents have tests ordered by an attending or mid-level in triage. A lot of big name programs have started doing this within the past 5 years and the real impact on their graduate product has yet to be realized. The fact that this educational threat is not being tracked for program accreditation is evidence that GME is a decade behind the times.

This literally destroys the EM specific trait that residents are supposed to learn in a quick visual/historical evaluation of a patient.

 

[Hercules]

I think it can work. It's just a question of do you really need it for a metric or some other specific goal and can your financial system allow for it.

DocB, you nailed it right here. It’s completely massaging a metric with no other intrinsic benefit.

I suppose as long as you assured everyone an equal distribution of these shifts it would all come out in the wash. But again, I can’t see a necessity for it other than artificially buffing door to doc times (which may help some admins bonus structure).

 

[ShockIndex]

DocB, you nailed it right here. It’s completely massaging a metric with no other intrinsic benefit.

I suppose as long as you assured everyone an equal distribution of these shifts it would all come out in the wash. But again, I can’t see a necessity for it other than artificially buffing door to doc times (which may help some admins bonus structure).

My former Chair would argue there is intrinsic benefit to a provider seeing patients before they elope and perhaps intervening on the few that are at risk for badness but missed by ESI scoring. To the best of my knowledge, quantifying that select few to a point of improvements in outcome is tough.

Of course, this assumes that the structural issues with department flow that leave patients languishing in waiting rooms (hospital crowding, using the ED as the sole means of unscheduled admission, etc.) are permanent and necessary fixtures.

 

[docB]

My former Chair would argue there is intrinsic benefit to a provider seeing patients before they elope and perhaps intervening on the few that are at risk for badness but missed by ESI scoring. To the best of my knowledge, quantifying that select few to a point of improvements in outcome is tough.

Of course, this assumes that the structural issues with department flow that leave patients languishing in waiting rooms (hospital crowding, using the ED as the sole means of unscheduled admission, etc.) are permanent and necessary fixtures.

Good points. I wish I could say that our scheme was based on a desire to improve patient outcomes. On the other hand some have pushed these ideas to make $ by turning LATs into billable charts and that really wasn't it either. No, it was because we were told to eliminate LATs. No justification. Just a metric. Meet this or else. Yesssssir! Right away sir! You guys keep doing CPR. I gotta go shake this guy's hand. BRB. Sad but true.

This did have the effect of highlighting some of the kafkaesque absurdities of "data driven medicine" when operated by people who don't understand statistics, bias or the law of unintended consequences.

• Eliminating LATs is bad. Don't get me wrong. I'm aware of shops that have LAT rates in the 20% range which is a mess. But if you eliminate all LATs you wind up capturing and billing registration errors and misunderstandings. I've seen people checked into the ED as patients who came for outpatient lab draws or radiology studies, were trying to find the wound center or their doctor's office, were actually here to visit someone in the hospital and so on. These patients SHOULD turn into LATs after the triage nurse clears up the confusion or registration fixes the error. But with me breathlessly pumping their hand and spewing a quick batch of scripted crap all over them they turn into a 99283. And that's bad. We don't collect that. They complain, rightly so, and we have to research the issue and write it off. It costs us time and money to go through the motions. I'm convinced that ED LATs should be ~1% to allow for these issues. Trying to force it to less than that just causes problems.
• Because of PG/HCAHPS nonsense these patients become a priority. In all my shops it's only the discharged patients who are surveyed because admitted patients have shown a complete inability to understand the difference between their EP and their admitting doctor, surgeon, nurse, housekeeper or the curtain in their room. Anyone who's done some admin has fielded complaints, duly forwarded on by hospital admin, about how the EP botched their cholecystectomy or didn't call the family on hospital day 5. So if you want to improve your PGs you have to focus on the low ESI patients who will be discharged. And focus on the least sick of those because you can get them out super quick and they'll be joyous. Never mind that by definition most patients who are discharged probably didn't need to be in an ER anyway or that none of us got into EM to be the best customer pleasing med refiller we could be. Nope, we are to neglect the sick and pander to the well like the pathetic PG ****** we have become.
• This can also result in more doctor specific complaints. When someone has to wait in the waiting room they get angry at the ED or the hospital. After one of us has dutifully jogged out, prostrated ourselves, proffered the required business car... ahem... "patient care card" (sadly not kidding) the patient tags us with whatever happens after that. Once I've said Hi anything bad after that, the wait, a bad IV start, stale sammich, TV not working, the weather, are all on me.

As to the point about hospital issues being the source of flow problems in the ED I quite agree. Traditionally fixing those issues requires the hospital to spend money so it takes a distant back seat to flogging the contract groups which is free. It rarely works but the failure has the added bonus of giving hospital admin an additional bargaining chip at contract time. Wheeeee!

Sorry if I'm ranting. That's never happened before. And I'm sorry for derailing the thread a little. To bring it back I don't discount the provider triage scheme to meet metrics and help improve outcomes. I do note some logistical barriers and I have deep misgivings about EM being saddled with poorly thought out metrics.