Over the past five years, emergency department wait-times have increased, and more patients are leaving before receiving care. Rapid Medical Evaluation (RME) programs have been proven to improve wait times and patient satisfaction. This article will describe the RME process and demonstrate how it can successfully be applied to Emergency Departments (EDs).
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Patients spend the majority of their time in processing before even seeing a physician. Rapid Medical Evaluation (or Rapid Clinical Evaluation) is a system to ensure that patients are evaluated and treated as quickly as possible. In most EDs, patients are initially triaged by a nurse to decide on the level of acuity. In RME, patients are initially triaged by a physician. After being assessed, they are sent to the waiting room unless they are flagged as having an emergent condition. RME provides patients with the answers and care they need as soon as possible, and allows physicians to determine a patient’s priority of care starting in the waiting room.
Ambulatory patients most affected by RME. They comprise of:
- Low acuity patients – investigation or treatment of illness or injury can be delayed or referred to other areas of the healthcare system
- Occult high acuity patients- investigation or treatment needs to be done on an emergent basis (i.e stroke, chest pain, trauma)
It is important to distinguish between occult high acuity and low acuity patients in order to facilitate proper treatment efficiently.
RME has three main steps:
- The triage physician performs focused history and physical exam and determines the appropriate initial testing and basic treatment. Each patient arriving by triage is seen and then handed over to the main ED physician. The triage physician does minimum documentation in the medical chart and has no responsibility for the patients in the main ED.
- Each patient returns to the waiting room unless urgently in need of a bed. Patients will then proceed directly to a dedicated care area where diagnostic tests and treatments are performed.
- The main ED physician will reassess patients once their treatment and testing are completed; the physician then assumes care and discharges or refers patients as appropriate.
Redesigning the triage area can have a significant effect on patient flow. The waiting room can be divided into three zones:
- patients waiting for initial assessment
- patients waiting for diagnostic tests
- patients waiting for test results
This can ease the transition and flow of patients in the waiting room.
Red Flag Status
The triage physician can assign patients “red flag status” if they meet criteria for a medical emergency (trauma, chest pain, stroke, etc).
- “Red Flag” patients are sent immediately to the main ED for treatment
- All other patients are returned to the waiting room and then seen by a mid-level provider, i.e. senior nurse or nurse practitioner
This process reduces the traditional use of the waiting room as a “holding station” before the patient even reaches a provider.
- Patients can be seen by a physician earlier
- Occult high acuity patients can be identified earlier
- Diagnostic tests can be ordered before an ED bed is available
- ED beds are reserved for higher acuity patients
- New handover requirement from triage physician to main ED physician
- Patients may dislike being sent back to waiting room after testing
- May require more resources by requiring an extra physician in triage
- Main ED physician may disagree with triage physician assessment and plan
REM is an effective way to reduce patient wait times and length of stay while maintaining high-quality emergency care.
- Crane, J & Noon, C. (2011). The Definitive Guide to Emergency Department Operational Improvement: Employing lean principles with current ED best practices to create the “no wait” department. Boca, FL: Taylor & Francis Group.
- Emergency department care redesign using the novel rapid process optimization (RPO) methodology: University of Colorado Hospital
- Reducing emergency department length of stay using rapid clinical examination: Memorial medical Center
- Rapid entry process: USCD Medical Center: Hillcrest
- The initial assessment process: St. Joseph’s healthcare Hamilton