Taking a new posture

Case study: How electronic triage supports efficient spine care in one surgical group - and how you can adapt the approach for your practice

The Mayfield Clinic & Spine Institute, a Cincinnati neuroscience group practice, found itself increasingly challenged during the late 1990s with timely management of a large volume of patients with spinal symptoms. The traditional method of handling patient flow, in which we scheduled a patient for the next available appointment without an initial assessment of spine-related symptoms, was becoming more and more unwieldy.

An analysis of several thousand patients showed that the mean waiting time for a patient's first appointment was 30 days, with peak times as long as eight weeks; only 22 percent of these patients were surgical candidates. The result was that patients who truly required surgery waited in line behind patients who did not require surgery, while those with less serious problems waited unnecessarily for an appointment with a surgical specialist who would most likely refer them to a different medical professional. Not surprisingly, referring physicians and patients expressed frustration with these delays, and customer-satisfaction research showed waiting times as the foremost complaint.

As a result of our analysis, we launched a new spine triage system, with impressive results. This approach could be adopted by any other surgical practice.

Collaborative database: First step in streamlining triage

We began our effort to improve the efficiency and service of managing spine patients in October 2001 by creating a collaborative database designed to facilitate triage. The database includes medical histories and symptoms drawn from patients during 15- to 30-minute phone interviews conducted by trained support staff. These employees, called intake specialists, use standardized medical history questions developed by Mayfield neurosurgeons that include type, intensity and duration of symptoms, as well as prior testing and treatment. Key follow-up questions, driven by clinical algorithms or past medical history and co-morbid conditions, are recorded. The intake specialists ask patients if they have additional information to share with the surgeon and to bring films, if available, to our office.

After each intake interview, a surgeon reviews all medical information on a personal computer, along with any radiology images. He or she then either orders a surgical appointment for the patient or refers him or her for nonsurgical treatment that typically involves physical therapy, pain management or other appropriate professional service.

Potential surgical candidates' information is transmitted electronically by the neurosurgeon to the intake specialist, who calls the patient and schedules a first appointment. Patients who are considered unlikely surgical candidates are called by a registered nurse care coordinator, who conveys the surgeon's assessment and conservative treatment recommendations. The care coordinator educates the patient about his or her condition and the likely outcome of treatment, and otters assurance of an expedited appointment if therapy results are unsatisfactory. The patient receives additional written material and a copy of the care plan sent by the surgeon to the referring physician. The care coordinator remains a resource for the patient throughout therapy and follows up with him or her and the therapist at the end of the treatment period. The flow chart below depicts the triage process.

Contrasting cases show the triage program's effect

The success of our triage system is reflected by two contrasting cases. In the first instance, a patient came to Mayfiekl with diagnostic images indicating a herniated cervical disc and a history that included treatment with anti-inflammatory and pain medications. Within two days, the neurosurgeon reviewed the history and imaging scans, determined that the patient had a moderate-sized herniated cervical disc and recommended physical therapy prior to a surgical decision. The patient began physical therapy within three days of the neurosurgeon's review and experienced a resolution of symptoms within four weeks. The patient notified the care coordinator of her recovery and decided to forgo an appointment with the neurosurgeon.

In a dramatically different case, a referring physician's office provided Mayfield with initial information that did not convey the seriousness of the patient's condition. Under the old system, this patient would have received the next available appointment, which could have been weeks in the future. Under the triage protocol, however, the intake specialist contacted the patient to obtain a complete medical history, which revealed symptoms of uncoordinated movement, urinary incontinence and tingling sensations.

Recognizing the seriousness of the symptoms, the intake specialist immediately described the case to the care coordinator, who asked the primary physician's office to speed X-rays and the radiology report to Mayfield. Within one hour of the initial call, the consulting neurosurgeon assessed the patient's information and identified symptoms of upper spine disease. The patient saw the neurosurgeon that day, was admitted to the hospital from the office and underwent surgery the following day.