Best Practice and
American Hospital Association NOVA Award
Submission
Department of Primary Care Nurse Greeting Center
in the Emergency Department
Point of Contact: LTC Richard Behr, Clinical Nurse OIC, Department of Primary Care,
richard.behr@amedd.army.mil, 719-524-5664
Group involved with the project: Evans Army Community Hospital Department of Primary Care (DOPC)
(to include all outlying clinics); Emergency Department (ED); Resource Management Division; Medical
Management Division; Medical Treatment Facility (MTF) leadership
Submitted by CPT Melissa Thomas
May 10, 2012
Executive Summary: A nurse greeting center staffed by the Department of Primary Care was
established to reduce non-urgent care in the Emergency Department. The greeting center obtains
patients a same day appointment or refers them to their assigned clinic on a walk-in basis. In
eight months, 2,040 patients were redirected saving $137,000.
Objective of the Best Practice: A nurse greeting center staffed by the DOPC in the ED in
Evans Army Community Hospital (EACH) was established to reduce non-urgent patient care in
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Final Project Portfolio
the ED, thus advancing patient safety, improving continuity of care, and reducing waiting times
and costs.
Background: Military MTFs are in the process of implementing patient centered medical
homes (PCMH) to improve provider continuity with their primary care manager, patient
satisfaction, and overall health outcomes. Additionally, the Performance Based Adjustment
Model (PBAM) both financially incentivizes and punishes certain patient behaviors and health
system management processes. One such decrement is a penalty for non-emergent RVUs seen in
the ED, and one such reward is for provider continuity. Due to these factors, a multidisciplinary
team was formed to address the goal of reducing non-urgent care in the ED without hiring
additional staff. An observation period determined a potential for improvement in the triage
system and acquiring appointments for patients who presented at the ED with non-urgent issues.
Literature Review: Inappropriate emergency department utilization is common worldwide;
therefore a lot can be learned about the Department of Defense population from studies of
populations in countries with socialized medicine. Studies in Brazil and Singapore show that
inappropriate use of the ED was due to unavailability of primary care appointments or an
overestimated self-perceived urgency. Success in changing patient behavior was achieved
through education/campaigns about the appropriate use of medical services as well as financial
incentives, which must be combined with expanding access to primary care for the best effect
(Anantharaman, 2008 and Carret, Fassa, & Kawachi, 2007).
Implementation Methods: The method used at EACH was establishing a nurse greeting center
staffed by the DOPC co-located with the ED triage registered nurse (RN). The nurse greeting
center is manned during daytime hours consisting of a Primary Care RN and medical staff
assistant familiar with the appointment booking system. The RN triages patients for clinic
appointments when the visit is clearly non-urgent as well as educates patients on non-urgent
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conditions and procedures for obtaining appointments. If no appointment is available, patients
are referred to their assigned clinic on a walk-in basis following direct telephonic communication
with the accepting clinic.
Results: Implementing this process resulted in a statistically significant rise in the percentage of
patients triaged out from the ED to a primary care clinic (shown in Figure 1), as well as a
statistically significant drop in the percentage non-urgent of total ED patients (Figure 2). In eight
months, over 2,040 patients were redirected to a primary care clinic with a cost savings of
$137,000 (using $67.10 per patient cost difference of a primary care encounter versus ED visit).
Conclusion: This program is easily replicated in its entirety at every DoD Facility with an ED
without additional funding. One unique element is utilization of primary care nurses and staff to
implement the program who are familiar with the scheduling process and various available
clinics, versus Emergency Department staff, which was tried at other military facilities, which
adds to their workload and is out of their scope of responsibility. Additionally, this program is
unique in that it did not require any additional funding or staff, although now that the pilot
program is complete, the process is in place to hire an RN solely for this position to minimize the
impact of periodically losing an RN from the primary care clinics for a day.
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Figure 1. Percentage of ED Patients Triaged Out from the ED to a Primary Care Clinic. This figure compares the
average percentage of patients triaged out before and after project implementation.
Figure 2. Percentage of Non-Urgent Patients of Total ED Patients. This figure compares the average percentage of
non-urgent patients seen in the ED before and after project implementation.
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References
Anantharaman, V. (2008). Impact of health care system interventions on emergency department
utilization and overcrowding in Singapore. International Journal of Emergency
Medicine, 1:11-20.
Carret, M., Fassa, A., & Kawachi, I. (2007). Demand for emergency health service: factors
associated with inappropriate use. BioMed Central Health Services Research, 7(131).
Meyers, M. (2003). Changing business practices for appointing in military outpatient medical
clinics: the case for a true “open access” appointment scheme for primary care. Journal
of Healthcare Management, 48(2): 125-139.
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