title: Applying lean: implementation of a rapid triage and treatment system.
abstract: OBJECTIVE
  Emergency department (ED) crowding creates issues with patient satisfaction, long wait times and leaving the ED without being seen by a doctor (LWBS). Our objective was to evaluate how applying Lean principles to develop a Rapid Triage and Treatment (RTT) system affected ED metrics in our community hospital.
  
  
  METHODS
  Using Lean principles, we made ED process improvements that led to the RTT system. Using this system, patients undergo a rapid triage with low-acuity patients seen and treated by a physician in the triage area. No changes in staffing, physical space or hospital resources occurred during the study period. We then performed a retrospective, observational study comparing hospital electronic medical record data six months before and six months after implementation of the RTT system.
  
  
  RESULTS
  ED census was 30,981 in the six months prior to RTT and 33,926 after. Ambulance arrivals, ED patient acuity and hospital admission rates were unchanged throughout the study periods. Mean ED length of stay was longer in the period before RTT (4.2 hours, 95% confidence interval [CI] = 4.2-4.3; standard deviation [SD] = 3.9) than after (3.6 hours, 95% CI = 3.6-3.7; SD = 3.7). Mean ED arrival to physician start time was 62.2 minutes (95% CI = 61.5-63.0; SD = 58.9) prior to RTT and 41.9 minutes (95% CI = 41.5-42.4; SD = 30.9) after. The LWBS rate for the six months prior to RTT was 4.5% (95% CI = 3.1-5.5) and 1.5% (95% CI = 0.6-1.8) after RTT initiation.
  
  
  CONCLUSIONS
  Our experience shows that changes in ED processes using Lean thinking and available resources can improve efficiency. In this community hospital ED, use of an RTT system decreased patient wait times and LWBS rates.
authors.affiliation: Kaiser Permanente, Department of Emergency Medicine, South Sacramento Medical Center.
authors.forename: Karen L
authors.initials: KL
authors.lastname: Murrell
authors.forename: Steven R
authors.initials: SR
authors.lastname: Offerman
authors.forename: Mark B
authors.initials: MB
authors.lastname: Kauffman