“Who’s Missing?” Quality Improvement Lessons from Redesigning Emergency Department Triage

“Who’s Missing?” Quality Improvement Lessons from Redesigning Emergency Department Triage

2021 was a defining year for many healthcare workers. While 2020 brought unimaginable challenges, 2021—marked by the Delta variant’s surge —pushed systems to their absolute limits. Emergency departments (ERs) across the country saw skyrocketing patient volumes, higher acuity, and overwhelmed teams scrambling to manage the unmanageable.

In the ER where I worked, the year began to feel like an endless game of catch-up. Patients weren’t just arriving in larger numbers; they were sicker. Our average triage acuity scores were significantly higher than in 2019, the so-called “before times.”

Compounding the crisis, hospital beds across the region were scarce, leading to delays in admissions and gridlocked emergency departments. This led to swelling waiting rooms and a system stretched to the breaking point.

When the System is Maxed Out

The ER operates like a conveyor belt. Patients arrive through the ambulance bay or walk-in entrance. From there, they’re either treated and discharged or admitted to the hospital. But in 2021, this system was failing. Admissions rose sharply due to the severity of patient conditions, but staffing shortages and limited physical beds slowed outflow to a crawl.

For every person admitted, dozens remained stuck in the waiting room, waiting hours for care.

For triage nurses, this was a nightmare. Imagine overseeing a waiting room with 40, 50, or even more patients—many of them seriously ill—and knowing that you can’t move them into care as quickly as they need.

It’s a helpless, heart-wrenching position to be in.

The Triage Redesign: Thinking Outside the Bed

To address this crisis, our service design committee identified triage as the strategic priority. We knew we couldn’t magically create more hospital beds, but we could change how patients flowed through the ER.

The result was a triage redesign centered on the Provider in Triage (PIT) program. Here’s what we did:

• Expanded the Triage Team: Added more nurses and techs to better handle patient volumes.

• Provider in Triage: Embedded an advanced practice provider (APP) directly into the triage team to expedite care decisions.

• Extended Triage Area: Created additional space where patients could receive labs, imaging, and medications—even if they couldn’t be placed in a traditional ER bed.

  
  

We didn’t invent these ideas in isolation. Our committee conducted a literature review and borrowed best practices from other institutions, combining them into a hybrid model tailored to our department’s needs. The goal was simple: ensure patients received care as quickly as possible, even if they couldn’t immediately access a bed.

What Happens in Triage Affects Everything

Redesigning triage doesn’t just change what happens at the front door. It shifts workflows across the entire emergency department. Every new process in triage touches multiple stakeholders—from radiology to transport teams—making communication and coordination critical.

This brings me to a lesson we learned the hard way.

The CT Communication Error

When rolling out our new triage process, we communicated changes to key stakeholders: X-ray, MRI, and other critical teams. But we overlooked CT. I’m not sure if we assumed CT wouldn’t be affected or simply missed them in our planning, but the oversight became glaringly obvious on day one of the pilot program.

CT staff were frustrated—and understandably so. They hadn’t been informed about the new extended triage area, and patients they needed for scans weren’t where they expected them to be. The lack of communication disrupted their workflow and strained relationships. As the project leader, it fell on me to address the situation.

I had to work quickly to rebuild trust, educate the CT team on the new process, and integrate their feedback into our next iteration. This mistake became a valuable learning moment for the entire committee. It highlighted a common pitfall in systems change: forgetting to ask, Who’s missing?

Reflective Takeaways: Asking Who’s Missing

Whether you’re redesigning a triage process, launching a new program, or simply solving a team issue, it’s essential to ask early and often: Who’s missing?

Consider these questions:

• Who interacts with or is affected by this process that we haven’t included?

• Whose insight could help us better understand the problem?

• Who needs to know about this change before we roll it out?

In complex systems, it’s impossible to include everyone, but drawing clear boundaries and ensuring key stakeholders are involved within those boundaries is critical. Inclusive design leads to better solutions, stronger buy-in, and smoother implementation.

Building Resilience Through Iteration

Mistakes are inevitable in change projects, especially in high-pressure environments like emergency departments. What matters is how we respond. For our service design committee, the CT oversight was a humbling moment but also an opportunity to improve. By iterating on our process, we built stronger relationships and ensured smoother rollouts in the future.

This resilience—the ability to learn, adapt, and improve—is at the heart of nurse-led healthcare change. It’s not about being perfect; it’s about staying committed to doing better.

Take the Next Step

If this story resonates with you, don’t stop here. Subscribe to the Nursing the System Podcast on Apple Podcasts or Spotify for more stories, strategies, and lessons (like this one!) on driving change in healthcare. Join the Systems Sunday Email List for weekly insights to help you lead with confidence and clarity.

The next time you’re solving a problem, ask: Who’s missing? You might be surprised by how much better your solutions become when everyone has a seat at the table.