RME: Rapid Mediocre Evaluation

Rapid Medical Evaluation is one of the latest buzz words for programs promoted used by ED Physician groups to promote faster ED throughput and market their groups to hospitals. Its similar to “Provider is Triage”, “Triage Bypass”, and “Door to Doc” programs some of which I have written about before and so have others here. RME is proprietary to a California ED group, California Emergency Physicians (CEP).

The premise goes something like this. Patients presenting to the ED can be rapidly divided into 2 groups the sick and less sick based on a quick look rather than a full triage. This is done by bringing every patient upon presentation immediatly back to a intake area staffed with a physician or more commonly a PA and a Nurse or in some cases only a PA, tech, and unit clerk. After a quick focused interview by the provider the patient is put into one of the 2 categories. The sick group goes to the main ED for treatment. The less sick group may either be discharged on the spot or sent off to various areas for lab or radiology studies. The less sick group does not own a bed and rarely gets undressed. The less sick group is not assigned to a Nurse in most cases. They move about the hospital similar to the way you would move from area to area in a clinic setting basically on their own and once all the results are in they are dispo’ed. The benefits reported are quicker door to provider times, fewer Left Without Being Seen patients, and more revenue for the hospitals and ED groups.

Some of this sounds good but lets peel back the onion and look beyond the marketing aspects and flashy improvement of ED metric’s that some of these programs report. Since these programs are primarily focused on the low acuity patients do they really do anything about ED overcrowding. The primary reason ED’s are in crisis is not a large volume of low acuity patients. If there is a back up of low acuity patients waiting to get into fast track is that a crisis that endangers patient safety, usually not. It’s the high acuity patients and the difficulties in dispositioning those patients that is the majority of the problem. Lack of inpatient beds or staff, lack of specialist coverage, lack of primary care, and an aging population being the main culprits. ENA has a well refrenced position statement on ED overcrowding that examines the issue.

None of these programs are consistent with national standards for Triage which usually gets eliminated or stripped down when RME is implemented. Both ENA and ACEP have endorsed a 5 level triage system. ENA and ACEP have a joint position statement here. ENA at their 2007 meeting specifically endorsed either the 5 level Canadian Triage Acuity System (CTAS) or the Emergency Severity Index (ESI) Historically ED triage systems have been 3 level and the research has shown that the 3 level systems have poor reliability and predictive value where as the 5 level systems have good predictive value. So now were supposed to believe that a 2 level system is the way to go. Perhaps the biggest flaw is the assumption that the majority of ED visits can be can be reduced to a quick look and a 3 minute interview a couple of tests, a quick prescription (likely not indicated) and disposition out the door. Many low acuity presentations are obvious but you will get burned by practicing like most are. Elderly and special needs populations even when presenting with a minor stated complaint need an history, physical exam, vital signs, and Nursing assessment.

Administrators see these programs as a way to reduce Nursing hours. CEP claims in their web site that the less sick patients do not need to be assigned to a Nurse. Kind of an end run around the California Nursing Ratio’s

“A corollary of RME to rapid care is the more efficient utilization of nurses and the elimination of many nurse hours that are required for compliance with many regulated state and healthcare system nurse:patient ratios. For example, by seeing, caring for and discharging a patient directly, and eliminating the need to count that patient as being in a bed in the ED, significant nurse hours may be reduced in the ED. Nurses find professional satisfaction with a career in an efficiently run ED, thus lowering hospital recruitment and retention costs”

So if patients only need ancillary testing they wont get counted in the Nursing Ratio’s? The promoters want it both ways. They want to end the Nurse Patient relationship with the less sick patients but in the real world a Nurse gets assigned many of the tasks to process the patient in and out and most regulatory agencies require some form of Nurse involvement. I have news for CEP. If a Nurse assess, gives medication (even Tylenol), performs a treatment, draws blood, performs a breathing treatment, or discharges a patient a Nurse Patient relationship is established and the patient is counted in the ratio’s, at least in California. You can not reduce Nursing to a series of tasks as much as you’d like to.

But what about the numbers, these programs produce great numbers! Yes, some do, especially if you don’t have a good understanding of statistics and view all patients as equal. The focus in the promotion is 3 primarily ED metric’s, LWBS, Door to Provider, and Patient Satisfaction scores with Patient Satisfaction scores being one of the biggest drivers. Because most high acuity patients get excluded from the satisfaction surveys the scores represents a skewed representation of what an ED does. The published metric's I have seen at the links here and others are relatively short duration measurements with no outcome studies. They avoid the subject of return ED visits rates, missed findings, morbidity and mortality from doing an inadequate exam or work-up or having the patient seen by a PA instead of a MD, or the negative effects of eliminating an effective Triage system. If you discharge patients before they have a chance to leave without being seen your LWBS rate will decline. You can drive down the door to provider time by putting the provider at the front end of the process but what does this do for the back end high acuity patients. Patients generally will be happier if waits are reduced, even if the care is sloppy. And finally, most of these programs are implemented simultaneously with other process changes such as bedside registration, expanded fast track capacity and hours, and immediate bedding which have been shown to be very effective. My experience is that the credit for the improvement is claimed by the RME type processes promoters when it would more accurately go to the bedside registration, expanded fast track, and immediate bedding processes The rest is window dressing and mediocre care designed to sell the services of the ED group promoting it and buff satisfaction scores.