Improving access and flow: reflections on deploying an Emergency Department electronic triage solution

SWL Digital Pioneer Fellow: Jacqueline Marks

Role: Senior Programme Manager, Unplanned Care
Organisation: Kingston and Richmond NHS Foundation Trust

Digital e-triage

Summary: Implementation of an electronic booking and triaging system at the front door of Kingston Hospital’s Emergency Department (ED).

Story of the project

Following a visit to Kingston Hospital from the Emergency Care Improvement Support Team (ECIST) in 2022, recommendations were made to improve the flow through the Emergency Department (ED), particularly the reception and triage area.

In 2023, work began on the implementation of an electronic booking and triaging system for the site, which included interoperability with the current EPR system, Oracle, and the Trust Integration Engine (TIE).  

The key aims for updating the existing analogue system to a digital booking and e-triage system include:

• allow clinicians to have sight of the sickest patients more quickly;
  
• reduce waiting times; and
  
• improve time to treatment and appropriate streaming through the department, thereby improving the patient journey so they are seen in the right place at the right time.

By the beginning of the SWL Digital Pioneer

Fellowship in summer 2024, progress with implementing the system had been stalled. This included two postponed dates to go live, and a further delay due to a major issue around safeguarding. Multiple phases of testing and issue resolution followed, prior to a rolling date to go live in January 2025.

Driving project development through the SWL Digital Pioneer Fellowship

I applied for the SWL Digital Pioneer Fellowship through interest, with ambitions to gain further knowledge and meet like-minded people. 

The Fellowship exceeded my expectations. Meeting and building relationships with other digitally-focused Fellows, both across south west London but also in my own Trust, has been wholly beneficial. 

The most valuable part of the Fellowship has been our action learning sets and collaborating with other Fellows to find solutions to timely issues from our projects. The Fellowship offered both validation and reassurance from those who had experienced similar challenges.

Outcomes

Kingston Hospital now has seven iPad kiosks in its Emergency Department entrance for patients to check themselves in. This has lead to the following improvements:

1. Early identification and prioritisation of sickest patients: this includes a reduction in the time to initial assessment and time to treatment with a clinician. 
   
2. Improves patient flow: time in department/acuity score was used as the metric for this benefit. Acuity is assigned by the first member of clinical staff to assess the patient on a scale from one to five (1: immediate emergency care, 2: Very urgent emergency care, 3: urgent emergency care, 4: standard emergency care, 5: low acuity for emergency care). Year-on-year there has been a marked improvement for 4s and 5s, which are usually streamed through urgent treatment centres (UTC). Improvements have particularly been for 4s, who trigger a sustained Statistical Process Control (SPC) improvement at six months.
   
3. Standardising flow-reducing variation: the numbers of patients moved from majors to UTC has improved year-on-year, with the improvement from Q1 (April to June) 2024 to Q1 2025 at 14%.

Next steps

Feedback from patients has been central to the next stage of this project. A review of the patients’ experience was triangulated with observations of the reception and check-in area. Key findings include:

• 8 out of 64 patients mentioned there being some confidence in the digital system for patients, which is unusual for a process.
  
• From 28 comments mentioning receptionists, 13 were actively positive (which is an improvement) while 13 were negative.
  
• Frustrations with digital check-in include length of time taken, repeated questions in the clinical setting and accessibility if too unwell to use the iPad.
  
• The flow process for the most unwell patients may need tweaking.

Next steps including ongoing monitoring of key metrics, as outlined in outcomes, as well as working with the supplier to improve the system and provide benefits at both a local and national scale.

For more information on the SWL Digital Pioneer Fellowship and check out our Innovation Directory to browse through the full list of Fellows.