Exploring New Intake Models
for the Emergency Department
American Journal of Medical Quality
XX(X) 1–9
© 2010 by the American College of
Medical Quality
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1062860609360570
http://ajmq.sagepub.com
Shari Welch, MD, FACEP,1 and
Steven Davidson, MD, FACEP, MBA2
Abstract
The objective of this article was to explore new intake models for processing patients into the emergency department
(ED) and disseminate these new ideas. In the fall of 2008, the Board of Directors of the Emergency Department Benchmarking Alliance (EDBA) identified intake as an area of focus and asked its members to submit new intake strategies
alternative to traditional triage. All EDBA members were invited to participate via an Email survey. New models could
be of their own design or developed by another organization and presented with permission. In all, 25 departments
provided information on intake innovations. These submissions were collated into a document that outlines some of
the new models. Collaborative methodology promoted the diffusion of innovation in this organization. The results of
the project are presented here as an original article that outlines some of the new and mostly unpublished work occurring to improve the intake process into the ED.
Keywords
quality improvement, emergency department, triage, learning community
According to the Agency for Healthcare Research and
Quality, the modern-day emergency department (ED) is
the point of entry for more than half of all patients admitted to the hospital in the United States.1 Coming through
this “front door” to the hospital are over 200 visits every
minute of every day in the United States, amounting to
an astonishing 40 visits to the ED per 100 citizens every
year. The patient visits involve complex medical issues:
43% of patients present to the ED with moderate to severe
pain, almost 40% of patients wait more than an hour to
see a physician, and one quarter of the patients seen in
the ED spend more than 4 hours there.2
On average nationwide, 3% of patients who seek
urgent health care will leave the ED without being seen
by a physician because of unacceptable waits and delays.3
These figures are even higher in urban settings with highvolume EDs. Thus, ED inefficiencies and delays translate into almost 4 million patients annually walking away
from health care after presenting for help. Given the complexity of the clinical setting, it should come as no surprise that The Joint Commission has found that the ED is
the most common site for sentinel events in the hospital as
a result of waits and delays in care.4
Timeliness of care is an issue that is front and center
for EDs in the United States and the world. The dialogue
about overcrowding has given way to discussions of
patient flow, how to measure patient flow, and how to
make improvements. Timeliness of care is among the
strongest correlates with patient satisfaction,5 and particularly, the time it takes to see a physician (door-to-physician
time) has the best correlation of all. By moving patients
quickly to patient care areas and having the physician
evaluate them in a timely fashion, patients perceive that
the wait time is acceptable.6,7 As the time interval from
patient arrival to the physician’s evaluation increases, the
rate of patients leaving without being seen (LWBS)
increases.8-10 Finally, with growing numbers of clinical
entities requiring treatment that is “on the clock,” timeliness of care begins with efficient intake of patients into
the ED.11-16
There is bureaucratic pressure to improve ED intake
processes as well. The Joint Commission now requires
hospitals to demonstrate that they track patient flow from
1
Intermountain Institute for Health Care Delivery Research,
Salt Lake City, UT
2
Maimonides Medical Center, Brooklyn, NY
The authors have no financial or other conflicts of interest to disclose.
Corresponding Author:
Shari Welch, Intermountain Institute for Health Care Delivery Research,
36 South State Street, 16th Floor, Salt Lake City, UT 84111
Email:sjwelch56@aol.com
2
American Journal of Medical Quality XX(X)
Table 1. Characteristics of Traditional Triage
Inefficient
Many repetitive steps
Steps have no value to the patient
Processes occur in series, not in parallel
Long door-to-physician times
intake into the ED through the inpatient side.17 This is in
addition to the core measures established by The Joint
Commission that involve tracking clinical care critical
actions and timeliness for specific disease entities like
acute coronary syndrome, congestive heart failure, and
pneumonia. Furthermore, in October of 2008, the National
Quality Forum endorsed 10 quality and performance measures for the ED.18 This was the culmination of a 3-year
process that involved vetting recommendations from
numerous quality organizations and technical expert panels. These 10 quality measures include 5 clinical measures
and 5 operational measures, the latter including door-toprovider time and its close cousin measure LWBS. These
measures are expected to form a foundation for the Centers
for Medicare and Medicaid Services pay-for-performance
reimbursement plan for EDs.
Traditional triage often consists of 8 or 9 steps for the
patient prior to contact with the physician—steps that are
often repetitive, occurring in series instead of in parallel,
and add no value for the patient (Table 1, Figure 1). In this
study, a quality improvement collaborative sought information on alternatives to traditional triage for dissemination to its members.
Methods
The Emergency Department Benchmarking Alliance
(EDBA) is a nonprofit organization comprising 140 US
EDs and representing more than 5 million ED visits
annually. EDBA was founded in 1997 as an alliance of
performance-driven EDs. It operates as a quality improvement collaborative, sharing performance data and operational strategies to identify best practices. EDBA has
developed a benchmarks database and educational program and disseminates new ideas and innovations in print
and through conferences.19-26 In September of 2008, the
EDBA board of directors identified intake into the ED as
an area for collaborative study. An Email survey was sent
to all members asking for information about new intake
strategies being used or considered for trials at member
organizations. All EDBA members were invited to participate, and 25 sent submissions describing new intake models. New models could be of their own design or discovered
by another organization and presented with permission.
Many of the submissions involved unpublished trials.
The results were collated and distributed to the group.
Results
Table 2 summarizes some of the newer intake models being
trialed around the country, much of them as yet unpublished. The table presents a compilation of the ideas, models, and innovations submitted by participating members in
the EDBA intake models survey and collated for distribution to its members as a collaborative learning experience.
Midlevel Provider in Triage
For this alternative, the trend has been to elevate the
level of education and experience of the person in triage.
When midlevel providers (ie, nurse practitioners, physician assistants) are placed in triage, this change has
resulted in reduced throughput time, reduced waits, and
reduced rates of LWBS.27,28
Physician in Triage
There are ample data to support the placement of the
highest level of training at intake. Paramedics correctly
predict whether or not patients will need to be admitted
from the ED 62% of the time.29 In another study, Kosowsky
et al30reported how reliably the nurse could predict a
patient’s disposition. On the other hand, there is a growing body of evidence in the literature that demonstrates
that physicians’ assessments of outcome and disposition
are highly reliable, with 85% to 95% accuracy.31-34 Dedicating a physician to the intake process has a number of
advantages. Studies have shown that placing a physician
in triage decreases length of stay (LOS), decreases LWBS
rates, and increases staff satisfaction, and that approximately one third of patients can be rapidly discharged
using few or no resources.35-37 In the Triage Rapid Initial
Assessment by Doctor (TRIAD) study, throughput time
was decreased by 38%, with no increase in staff.
In response to a census that doubled in 5 years and
LWBS rates that had reached 20%, the staff at Arrowhead Memorial Hospital in California tested a physician
in triage model made possible by bringing in furniture
modules that created small cubicles in which physicians
could examine patients. Their experience revealed that
50% of patients could be discharged right from the cubicle (Figure 2). This opened up beds and reduced nursing
needs. Their LWBS dropped to 1%, and their time to see
a physician, which had begun at 4 hours, was reduced to
31 minutes.38
Team Triage
In 2004, a British team was among the earliest to suggest innovations, including advanced triage protocols,
care teams, and multidisciplinary triage in an article titled
3
Welch and Davidson
Patient presents
for evaluation
Name Entered
Traditional Flow Map of Intake
AMBULANCE
presents for
evaluation
Back to Waiting
Room
Initial
Assessment
Back to Waiting
Room
Placed in Bed
Primary Care Nurse
Assessment
Registration Calls
Patient
Physician Notified
Patient Ready
MD SEES
Back to Waiting
Room
Patient Brought to
Room
Figure 1. Flow map of traditional triage
Table 2. New Intake Models
Traditional triage staffing
Midlevel provider in triage
Physician in triage
Team triage
No triage, “pull to full”
Pivot nurse/abbreviated triage
Triage to the diagnostic waiting room
Intake kiosks
Bio identification techniques
Computerized self-triage
“A Paradigm Shift in the Nature of Care Provision in
the Emergency Department.”39 Since the first reports
about placing a physician in triage were first published,
many organizations have been experimenting with triage
alternatives (eg, team triage). Several innovators have
described success with having a team, often including a
physician, nurse, and technician, that converges at the
bedside to take the triage history together and formulate
a diagnostic/therapeutic plan.40,41
A variation on this has been called the clinical intake
area. In 2007, Gaston Memorial Hospital was seeing in
excess of 80 000 visits annually and had a LWBS rate of
12%. They created a clinical intake area in their department for approximately $800 and streamlined the process
to have a physician-led team examine, evaluate, and begin
treating patients even when a room is unavailable. Their
LWBS rates fell to 1.3%, and their Press Ganey scores
(patient satisfaction) rose to the 99th percentile.42
No Triage
Faculty physicians in the department of emergency
medicine at the University of California, San Diego,
4
American Journal of Medical Quality XX(X)
and sent to various patient streams. Using patient segmentation, like patients (those with similar LOSs and resource
use) are fed into 1 of 3 patient streams based on the likelihood of admission, the ESI at triage, the resources anticipated, and the LOS.
Triage to the Diagnostic Waiting Room
Figure 2. Arrowhead Memorial intake cubicle
have reported the most radical departure from traditional
triage—no triage. If there is a bed in the department, the
patient is brought back to a patient care space, and using
bedside registration, care of the patient begins. This has
led to reduced patient waits, decreased overall LOS, and
reduced LWBS rates. This model has also been trialed in
the ED Learning Community at the Institute for Healthcare Improvement, with similar success. This process is
sometimes referred to as the “pull until full” model for
intake.43 As long as there is an empty bed, patients are
brought straight into the department and intake is done at
the bedside.
Abbreviated Triage
At Mary Washington Hospital in Fredericksburg, VA,
Jody Crane, MD, tested a new abbreviated triage model.
Mary Washington is a high-volume ED; their census
topped 100 000 visits last year. A brief description of this
truncated intake process follows: there are 5 elements
included in this abbreviated triage, or initial assessment,
to help segment patients to the appropriate patient care
track. The 5 elements include the following:
single phrase chief complaint
allergies
pain scale
vital signs
emergency severity index (ESI Level)
At Mary Washington Hospital, it takes less than 6 minutes to triage a patient using this abbreviated scenario and,
with 2 triage nurses around the clock, new patient intakes
are performed at a rate of every 3 minutes.44 Dr Crane has
added even more innovation to the processes at Mary
Washington. Patients are assessed quickly by “pivot nurses”
The “Triage to the Diagnostic Waiting Room” is another
model that will seem very foreign to the health care
worker. For patients who do not need to be supine on a
stretcher during their ED stay, a physician in triage or team
triage approach is used, and testing is begun in a multifunctional triage bay. The patient is then sent to a cubicle
in a large waiting area with his or her family members.
Ample efforts are made to occupy the patient’s time
(among available resources are televisions, laptop portals,
DVDs, snacks, games, and phones). This model has been
used with success at Fairfax Inova Hospital in Fairfax,
VA. At St Joseph Hospital of Orange, an intake team
polices the waiting room and begins workups on selected
patients.45
In a variation on this model, the patient and family
members are asked to track the patient’s own progress
on a large plasma screen tracker and to notify the staff
when all test results are available. This involves the patient
in the process while off-loading the task of monitoring
for test results from health care providers. This frees the
clinical staff for other tasks. Using patients and families
to monitor results is called customer participation and is
a key strategy in demand/capacity management used in
other service industries.
Intake Kiosks
An even more futuristic vision for ED intake involves
both process redesign and changing the physical plant. In
the Annual ED ReDesign Course in Atlanta, GA, Jim
Augustine, MD, describes an ED of the future where there
are numerous rapid entry rooms. Patients pass through a
kiosk and swipe a health identification card that downloads all pertinent health information into the computer
system.46 A rapid assessment is done in these rooms.
Then, using protocols that are carefully crafted using pattern recognition for chief complaint data, patients are
assigned to the appropriate patient care stream. Assignment is done electronically and based on the chief complaint and vital signs. Registration occurs at the back
end—after the medical screening exam.
This futuristic model may not be so futuristic after all:
Wellington Regional Medical Center in Florida has already
implemented a “smart card” system that can be used in
a kiosk to register patients. These magnetic stripe cards
5
Welch and Davidson
link to the hospital information system and can locate all
elements of the patient’s electronic health record. The
information is password protected. Such an intake process removes traditional constraints to entering a patient
into the emergency health care system, and it is exciting
to imagine the operational improvements that will be
possible in this area.
Bio Identification Techniques
Bio identification may be an adjunct to the efficient operation of the intake process. Innovative centers have begun
trials using retinal scans, fingerprints, and palm scans to
create a unique health care identification for the patient;
these are extremely time-efficient methods. In particular,
the palmar scanning method of bio identification deserves
note.47 Steve Coluciello at Carolinas Medical Center has
streamlined his intake process by using palmar scanning.
At Carolinas Medical Center a palm print is used to generate an immediate identifier for a patient, which is then
tied to an ID number. The ID number is later married to
more demographic data. In less than 15 s, there is a way
to identify the patient for testing and treatment. The
device can ensure that the right patient is associated with
the right medical record number. In addition to preventing identity fraud and mismatched records, the device can
quickly identify unconscious or “altered mental status”
patients who were previously scanned. One such palm
scanning system is being marketed as the PASS system
(Patient Access Secured System; Simply Scan LLC,
Charlotte, NC).
Carolinas redesigned their intake area, putting recliners, a multitude of supplies, an electrocardiogram machine,
and point-of-care laboratory testing within reach of the
physician and his team. Often the low-acuity ESI 4 and
5 patients receive a disposition right from this area. In fact,
45.5% of patients were discharged by the physician from
triage. This is an effective way to off-load the main department when it is over capacity. These data are in line with
the findings of other departments that put a physician out
front: more than a third of patients seen by a physician in
triage can be discharged quickly from there. Carolinas has
seen improvement in door-to-provider time and the overall LOS during these trials.48
Computerized Self-Triage
Perhaps the most cutting-edge application of technology
to intake strategies has been reported by the University of
Western Ontario. At London Health Sciences Center, triage occurs using pattern recognition programming of data
that are entered by the patient into a computer in the waiting room. In the pilot feasibility study, the process was
surprisingly fast (5 min, 32 s) and easy to use (92% would
use again). In a substudy, the computer outperformed an
emergency physician at obtaining data elements for
patients with abdominal pain.49 This may be an effective
strategy for some subsets of patients who present to the
ED and will be part of our intake processes in the future.
Discussion
The impetus to change and improve on the intake process
for the ED is growing and is multifaceted. From improved
customer service/satisfaction and improved clinical outcomes to bureaucratic and regulatory requirements, the
pressures to improve the quality of ED processes is
growing. Every day EDs across the country struggle to
meet the growing demands of the patients who show up
at their doors, with capacity (in terms of space, staff, and
resources) that is regularly outstripped by demand. How
to match variable demand with fixed capacity?50 One
part of an effective patient flow strategy is to keep patient
flow through the health care system smooth and eliminate bottlenecks. One of the most commonly encountered
bottlenecks to flow in the ED today is one of emergency
medicine’s own making: triage.
Data show that 65% of ED patients are seen between
10 AM and 10 PM. The night shift sees only 35% of the
patient census.51 Patients are funneled into the department
using a traditional triage model, which takes between 12
and 20 minutes to process patients into the department.
These delays can be critical in terms of patient outcomes.
The following sidebar tells a common story of how ED
intake bottlenecks can detrimentally impact quality care.
This is an actual case from an EDBA hospital and illustrates how patient safety is at stake when the intake process for patients is delayed.
The pace is picking up as the evening wears on, and this
ED, like most EDs, struggles to manage the daily surge
that occurs. The triage nurse is taking the patients back
one at a time and is not keeping up with new arrivals. The
physician on duty is monitoring the tracking board and
notes with impatience that an elderly man has been waiting 45 minutes for triage. The tracking system “chief
complaint” notes that the man presented for evaluation of
“foot pain/no trauma.” The physician calls to his charge
nurse “Jill, can we bring that gentleman back? I am not
busy and I can see him now.” The nurse appears flustered
and under stress, “We’re going as fast as we can. It isn’t
injured. We’ll get him in a minute.” Several more minutes go by, and now, the elderly man has been waiting for
almost an hour to be seen. The physician studies him
through the triage window, noting that he seems to be in
pain and looks pale. The physician walks to the triage
waiting area and introduces himself. He asks the patient
6
about his symptoms and learns that the patient had sudden onset of pain and at the same time noted his foot was
getting cold. The physician kneels down and examines
the foot, removing the sock and shoe. He is sick himself
when he finds an ice cold foot that is turning black. There
are no pulses in the foot. The patient has occluded the
artery to his foot. Minutes count in terms of saving a limb.
Time was wasted.
As the ranks of the uninsured in this country grow and
resources for funding health care for indigent and lowincome populations shrink, the ED is the health care safety
net for many. No matter the insurance status or personal
resources, the ED will see and treat all comers. It is the
portal of entry into the health care system for many and
the first step in the continuum of care.
As increasing census has led to bottlenecks at intake,
most EDs are too busy managing the care of the influx
of patients to redesign the processes involved at intake.
This is true in many areas of health care but particularly
true for the ED in survival mode. How do you redesign a
department where service never stops? This means that
those EDs that have been able to innovate and discover
new, improved, and alternative processes can help move
the specialty forward in solving such problems. Those
model EDs and their governing organizations need a
venue to vet their findings and share their experiences.
Yet innovations and ideas to improve operations are
discovered by individual departments in a random and
haphazard manner. To date, no journal focuses on ED
operations, nor is there a textbook on ED processes to
reference for ideas about to innovate in the ED. The ideas
presented for dissemination in this article are the work of
a collaborative learning model implemented by the EDBA.
This demonstrates the value of such a model to advance
ED operations.
Limitations
This is by no means an exhaustive review of the innovations being trialed around the country to improve intake
models. It is the culmination of one organization’s collaborative learning project. Many of the new models and strategies are not yet published but are being disseminated at
conferences and through learning communities like this
one and those of The Institute for Healthcare Improvement,
the Voluntary Hospital Organization, Premier Healthcare,
and others. This is an effort to introduce the broader specialty to the topic and stimulate new areas of innovation,
dialogue, and research. This was a qualitative research
project, presenting the new intake models being trialed as
EDBA uncovered them. To date, there are not enough
data to perform a strong comparative analysis of each
model or a meta-analysis. That weakness is acknowledged,
American Journal of Medical Quality XX(X)
though such analyses may be possible in the future. The
goal of this article is to provide a forum for dissemination of these new operational strategies.
Conclusion
Concerns about delays in care in the ED have been
brought to the attention of the public by several highprofile news stories after patients have suffered dire consequences associated with long waits and delays in the
ED. In one case, a 49-year-old woman presented to triage
complaining of chest pain. She was triaged as semiurgent
but was sent back to the waiting room. She was not seen
immediately by a physician. According to records about
the case, she waited in the waiting room for more than
2 hours. When a nurse went to bring her back for evaluation
and care, she was not breathing, had no pulse, and was
still sitting in the waiting room. She was not successfully
resuscitated, and a subsequent homicide charge was filed
against the Vista Medical Center ED.52 In another case of
some notoriety, video surveillance cameras captured a
Jamaican woman slumping to the floor in the waiting room
of a psychiatric ED as apparently disinterested staff looked
on. She had collapsed on the waiting room floor and was
lying there for more than an hour before attempts were
made at resuscitation.53 In a third high-profile case, a
woman in an inner city “safety net hospital” lay screaming
in pain and vomiting blood in the waiting room. She finally
called EMS to transport her to another facility. She subsequently died of a perforated bowel and complications.54
Sadly, there are other stories. These cases point out in a
dramatic way the problems and dangers of delays in the
access to urgent and emergent care in our nation’s EDs.55
The public expects the health care system at large, and the
specialty of emergency medicine in particular, to solve the
access-to-care problems and intake issues.
There is a case to be made for rapid intake in terms of
the bottom line for the ED. The link between prolonged
intake processes into the ED (as measured by long doorto-physician times) and patients LWBS by a provider was
discussed at the beginning of this article and has a solid
foundation in the literature. Patients who leave without
being seen are in fact “customers” who have a higher than
likely ability to pay for their health care, either with insurance or with assets. Would any industry allow paying customers to walk away? With many health care organizations
struggling with narrower and narrower profit margins, it
is important to see the timeliness of care in the ED and
subsequent decrease in patients who walk away as a revenue capture opportunity.
The case for ED efficiency and clinical outcomes has
been made. At the beginning of this article, some references were cited from this body of literature (that is now
Welch and Davidson
growing at breakneck pace) that link timeliness of care
to improved clinical outcomes for a wide array of illnesses,
including acute myocardial infarction, pneumonia, stroke,
trauma, and sepsis. Because good outcomes are necessarily less expensive, timeliness and cost-effectiveness of
emergency care can readily be linked as well. And it all
begins with getting the patients into the ED in a timely
and efficient manner.
Besides the public scrutiny and attention to this area,
innovation will be of great interest to many quality organizations and to bureaucracies like Centers for Medicare
and Medicaid Services and The Joint Commission.
Although the Hospital Consumer Assessment of Healthcare Providers and Systems survey does not look specifically at the ED experience or timeliness of care, how
quickly patients’ pain is managed and how quickly patients
are seen are 2 of the biggest correlates with patient satisfaction. The National Quality Forum recently endorsed
10 measures for quality in emergency care. Two of the 5
operational measures include (1) time to be seen by a
provider and (2) left without being seen. Quality organizations and government agencies can be expected to drive
this agenda for emergency medicine within the context
of overall quality improvement in the ED.
The time to innovate and re-create the intake process
into EDs has come. The EDBA is a collaborative promoting innovation in ED care. A survey of its membership
uncovered and collected many new ideas and innovations
in lieu of the traditional triage model. These innovations
were compiled and disseminated to the EDBA. The purpose of this review is to introduce the larger specialty of
emergency medicine and its providers to these new models, technology, and physical plant changes that support
innovation at intake.
Declaration of Conflicting Interests
The authors declared no conflicts of interest with respect to the
authorship and/or publication of this article.
Funding
The authors received no financial support for the research and/or
authorship of this article.[AQ: 1]
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