Let me tell you a little story...
First a little background about me and the department. I've been doing ED nursing for about 5 years, the last 2 as a manager of the ED, and prior to that I held every EMS title that you can imagine, right up to COO. I continue to work for a nursing agency on the weekend, which give me access to 9 nearby hospitals to steal ideas that work! Our department is in an isolated community hospital, does trauma (level 2), has 23 beds in the main ER, 11 in Express, and 3 in the psych ER. Our clinical outcomes are excellent (in the top 5% of the country, per Healthgrades), patient satisfaction in the mid-80s percentile, and employee satisfaction is at about the 75th percentile.
Anyway, about 3 weeks ago, we changed our entire triage process. Prior to the change, a patient would present to a desk in the waiting room where a registration clerk would enter the patient into the system and complete a search of the medical records system to find the right patient. We also had a "Liason" at that desk who, so long as she was not working with the family of a critically ill or injured patient, would keep an ear on what patients' complaints were and would advise one of the traige nurses (who each had their own "office") that a seriously ill patient had arrived. The problem with the system was that the Liason had no real training and would miss the "hidden" ill patients - the MI with the atypical presentation, the sepsis patient who was hypotensive but still talking, etc.
So we changed things. A nurse now sits at that desk and does a really, really fast evaluation of the patient. She then decides where to put the patient - Critical Care, General Bed, or Express Care (Fast Track). One of the Triage Nurses will escort the patient back to the area and do triage in the room. Seriously ill or injured patients are picked off from the waiting room and sent back immediately - sometimes with a triage nurse, sometimes with the liason (who we are planning to teach EKGs, VS, and monitor leads next week) - just like an ambulance patient. We had some "dump and run" issues that were readdressed Thursday, which seems to have taken the pressure of the rest of the department. This process was based on one at one of the hospitals where I spent a couple of weekends. They had serious issues (including replacement of the entire ED leadership and most of the nursing staff and having state regulators in the ED to make sure that the behaviors that caused these problems did not repeat) and this was similar to their new system which worked wonders with their MI patients (and getting patients to the cath lab).
So what do we have for outcomes so far? We reduced the average door to EKG time on patient from 22 minutes to 2 minutes. We have reduced the time of placement of the first order (usually labs or an xray) from almost 48 minutes to about 21 minutes. Our front end is more efficient - now its time for us to work on our back end - the admissions!