The intake process is the first of the three main emergency department processes (see Figure).  Intake begins with patient arrival and concludes with bed assignment.  The complex actions that occur in between are critical to patient safety, especially when resources are suboptimal.  This article emphasizes the importance and structure of a rapid triage method.

ED waiting room deaths are notable because they are often preventable and seemingly ironic.  In July 2006, a 49-year-old woman entered an Illinois ED complaining of nausea, shortness of breath, and chest pain.  She was told to wait, and two hours later ED staff found her slumped in a chair, dead.  Two months later, a coroner’s jury classified her death as a homicide because the intake process resulted in a “gross deviation from the standard of care.”

When there are open beds available in the main ED, your ED can become more efficient by completely bypassing the formal triage process.While triage is meant to sort waiting patients, even when the patient goes directly back to an examination room, necessary components of the usual process (i.e., “quick registration,” brief assessment, prompt vital signs, and ESI score) should occur to help everyone keep patients accounted for and properly prioritized.  Bypassing a formal triage process significantly expands the number of effective “triage nurses,” eliminating a frontend bottleneck and reducing duplicative work. This plan requires all emergency nurses to be facile with the triage process. Even if a patient bypasses triage upon reception, the intake staff must initiate the “quick registration” so that the patient is tracked and orders can be initiated.  However, many busy EDs simply do not have the capacity to bypass triage for most of the day.  In these situations, a rapid ED intake process is outlined.

An essential component of ED intake is the triage methodology.  For purposes of this discussion, the Emergency Severity Index (ESI) is utilized.  However, other systems such as the Canadian Triage & Acuity Scale (CTAS) are also sound.  An important point is that no matter what triage systems is in place, the development of a rapid triage system may require it to be modified.

ESI 1 and 2 cases are “no-wait” situations comprising 24% of patients in a typical comprehensive ED.  Once identified at triage, all such patients must be immediately placed in the treatment area for emergent care and, ultimately, over half will be admitted.

ESI 3 cases are somewhat time-sensitive, consume several resources (e.g., labs, radiographs, medications), comprise 39% of patients, and one-quarter are admitted.  These patients should be moved to the clinical area in an urgent manner or should have testing, treatment, and comfort measures initiated on the front-end.
ESI 4 and 5 cases are non-urgent, can safely wait, and consume minimal resources.  These comprise 37% of patients and only one in one-hundred is admitted.  With these cases, great customer service improves the ED reputation and assures repeat business.

Minimizing door-to-triage time reduces risk and is accomplished by “right staffing” based on hour-of-day/day-of-week fluxes.  Additionally, “demand staffing” and other process adaptations are necessary to accommodate unexpected volume surges.  Emergency departments can learn a lot from other service industries.  For instance, we have all witnessed long grocery store check-out lines result in repositioning staff to open more registers.  As well, during the lunchtime rush, drive-through restaurants often separate order taking from cashiering (e.g., separate drive-up windows).  EDs that cannot effectively respond to surges result in unsafe situations and excessive LWBS cases.

Comprehensive patient registration must be completely disengaged from the intake process and largely performed at the bedside.  Pre-registration, however, is an integral intake sub-process so that the patient immediately appears on the computer tracker.  Pre-registration requires just enough demographic information to assign an account number and must be accomplished in 15-30 seconds.  Cutting edge EDs incorporate card swipe or biometric technology to facilitate pre-registration.  While triage nurses are often tasked with pre-registration, some centers flex a registrar to intake during surges.

Rapid triage is exactly what it sounds like and increases safety in two ways.  Bottlenecks are reduced because cycling time is shorter.  And, sick patients are literally pushed into the clinical area where they belong.  To follow are four chief components of one rapid triage model.