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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?
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?