Impact of revised triage to improve throughput in an ED with limited traditional fast track population

Models of care with advanced practice nurses in the emergency department: A scoping review

INTRODUCTION

Emergency departments play a critical role in healthcare systems internationally. Visits for emergency care continue to increase, related to poor access to primary care, the COVID-19 pandemic, and health human resource issues. International literature shows similar stressors in the emergency department. Extended wait times to see health providers lead to poor outcomes, and innovative models of care are needed to address emergency department overcrowding and to meet the needs of patients. Advanced practice nurses have the expertise and scope of practice to optimize and address primary and acute care needs and could be further integrated into the emergency healthcare systems. It is unclear what and how advanced practice nurses are functioning in emergency departments to improve patient and organization outcomes.

METHODS

This scoping review was a comprehensive search of MEDLINE, EMCARE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and gray literature. Authors developed inclusion and exclusion criteria, performed title and abstract screening, and full text screening using review software. Data about models of care with advanced practice nurses were extracted and organized to understand patient, provider, and organizational outcomes. We also extracted information about the development and implementation of roles.

RESULTS

Of the 6780 records identified, 76 met inclusion criteria. Emergency department models of care, mainly using nurse practitioners, include fast-track, generalized emergency, minor injury, orthopedics, pediatrics, geriatrics, specific populations, and triage. Reported patient outcomes include improvement in key metrics specific to emergency departments, such as total length of stay, wait times to be seen by a provider, left without being seen rates, treatment for pain, costs, and resource use. When comparing nurse practitioners to other providers, outcomes were similar or better for patient and organizational outcomes.

DISCUSSION

Various models of care utilizing advanced practice nurses in emergency departments are present internationally and information about how they are developed, integrated, and utilized provides practical information to support and sustain new roles. There is an opportunity to expand the use of these roles into emergency departments as the nurse practitioner scope of practice grows. Given the current crisis across healthcare systems, there is need for innovation, and improving delivery of emergency services with these advanced practice nursing models of care can help to address important health policy priorities in Canada and other countries.

TWEETABLE ABSTRACT

Advanced Practice Nurse models of care in emergency - Improved outcomes for patients and organizations - A review of the literature. @SamanthaH_RN.

Introducing a triage and Nurse on Call model in primary health care - a focus group study of health care staff's experiences

BACKGROUND

With the increased demand for health care services and with simultaneous staff shortages, new work models are needed in primary health care. In November 2015, a Swedish primary health care centre introduced a work model consisting of a structured patient sorting system with triage and Nurse on Call. The aim of this study was to describe the staff's experiences of introducing the triage and Nurse on Call model at the primary health care centre.

METHODS

Five focus group discussions with staff (n = 39) were conducted 4 years after the introduction of the work model. Groups were divided by profession: medical secretaries, nursing assistants, physicians, primary health care nurses, and registered nurses. The transcribed text from the discussions was analysed using qualitative inductive content analysis.

RESULTS

The analysis generated one overarching theme: The introduction of triage and Nurse on Call addresses changed preconditions in primary health care, but the work culture, organization, and acquisition of new knowledge are lagging behind. The overarching theme had five categories: (1) Changed preconditions in primary health care motivate new work models; (2) The triage and Nurse on Call model improves teamwork and may increase the quality of care; (3) Unclear purpose and vague leadership make introducing the work model difficult; (4) Difficulties to adopt the work model as it challenges professional autonomy; and (5) The triage and Nurse on Call model requires more knowledge and competence from nurses in primary health care.

CONCLUSIONS

This study contributes with knowledge about implications of a new work model in primary health care from the perspective of health care staff. The work model using triage and Nurse on Call in primary health care was perceived by participants to increase availability and optimize the use of resources. However, before introduction of new work models, it is important to identify barriers to and facilitators for successful improvements in the local health care context. Additional education for the health care staff is important if the transition is to be successful. Complementary skills and teamwork, supported by a facilitator seems important to ensure a well-prepared workforce.

Machine learning-based triage to identify low-severity patients with a short discharge length of stay in emergency department

BACKGROUND

Overcrowding in emergency departments (ED) is a critical problem worldwide, and streaming can alleviate crowding to improve patient flows. Among triage scales, patients labeled as "triage level 3" or "urgent" generally comprise the majority, but there is no uniform criterion for classifying low-severity patients in this diverse population. Our aim is to establish a machine learning model for prediction of low-severity patients with short discharge length of stay (DLOS) in ED.

METHODS

This was a retrospective study in the ED of China Medical University Hospital (CMUH) and Asia University Hospital (AUH) in Taiwan. Adult patients (aged over 20 years) with Taiwan Triage Acuity Scale level 3 were enrolled between 2018 and 2019. We used available information during triage to establish a machine learning model that can predict low-severity patients with short DLOS. To achieve this goal, we trained five models-CatBoost, XGBoost, decision tree, random forest, and logistic regression-by using large ED visit data and examined their performance in internal and external validation.

RESULTS

For internal validation in CMUH, 33,986 patients (75.9%) had a short DLOS (shorter than 4 h), and for external validation in AUH, there were 13,269 (82.7%) patients with short DLOS. The best prediction model was CatBoost in internal validation, and area under the receiver operating cha racteristic curve (AUC) was 0.755 (95% confidence interval (CI): 0.743-0.767). Under the same threshold, XGBoost yielded the best performance, with an AUC value of 0.761 (95% CI: 0.742- 0.765) in external validation.

CONCLUSIONS

This is the first study to establish a machine learning model by applying triage information alone for prediction of short DLOS in ED with both internal and external validation. In future work, the models could be developed as an assisting tool in real-time triage to identify low-severity patients as fast track candidates.

Impact of employing primary healthcare professionals in emergency department triage on patient flow outcomes: a systematic review and meta-analysis

OBJECTIVES

To identify, critically appraise and summarise evidence on the impact of employing primary healthcare professionals (PHCPs: family physicians/general practitioners (GPs), nurse practitioners (NP) and nurses with increased authority) in the emergency department (ED) triage, on patient flow outcomes.

METHODS

We searched Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) (inception to January 2020). Our primary outcome was the time to provider initial assessment (PIA). Secondary outcomes included time to triage, proportion of patients leaving without being seen (LWBS), length of stay (ED LOS), proportion of patients leaving against medical advice (LAMA), number of repeat ED visits and patient satisfaction. Two independent reviewers selected studies, extracted data and assessed study quality using the National Institute for Health and Care Excellence quality assessment tool.

RESULTS

From 23 973 records, 40 comparative studies including 10 randomised controlled trials (RCTs) and 13 pre-post studies were included. PHCP interventions were led by NP (n=14), GP (n=3) or nurses with increased authority (n=23) at triage. In all studies, PHCP-led intervention effectiveness was compared with the traditional nurse-led triage model. Median duration of the interventions was 6 months. Study quality was generally low (confounding bias); 7 RCTs were classified as moderate quality. Most studies reported that PHCP-led triage interventions decreased the PIA (13/14), ED LOS (29/30), proportion of patients LWBS (8/10), time to triage (3/3) and repeat ED visits (5/6), and increased the patient satisfaction (8/10). The proportion of patients LAMA did not differ between groups (3/3). Evidence from RCTs (n=8) as well as other study designs showed a significant decrease in ED LOS favouring the PHCP-led interventions.

CONCLUSIONS

Overall, PHCP-led triage interventions improved ED patient flow metrics. There was a significant decrease in ED LOS irrespective of the study design, favouring the PHCP-led interventions. Evidence from well-designed high-quality RCTs is required prior to widespread implementation.

PROSPERO REGISTRATION NUMBER

CRD42020148053.

Queueing Problems in Emergency Departments: A Review of Practical Approaches and Research Methodologies

Problems related to patient scheduling and queueing in emergency departments are gaining increasing attention in theory, in the fields of operations research and emergency and healthcare services, and in practice. This paper aims to provide an extensive review of studies addressing queueing-related problems explicitly related to emergency departments. We have reviewed 229 articles and books spanning seven decades and have sought to organize the information they contain in a manner that is accessible and useful to researchers seeking to gain knowledge on specific aspects of such problems. We begin by presenting a historical overview of applications of queueing theory to healthcare-related problems. We subsequently elaborate on managerial approaches used to enhance efficiency in emergency departments. These approaches include bed management, fast-track, dynamic resource allocation, grouping/prioritization of patients, and triage approaches. Finally, we discuss scientific methodologies used to analyze and optimize these approaches: algorithms, priority models, queueing models, simulation, and statistical approaches.

The Effect on Length of Stay After Implementation of Discharging Low Acuity Patients From Triage

Introduction Overcrowding in the emergency department is a complex and challenging issue across the nation. The increasing number of patients seeking care in the emergency department leads to overcrowding and therefore decreased available rooms and slower throughput. As part of a quality improvement project to improve throughput, we implemented a policy encouraging the discharge of non-emergent patients directly from triage. Methods This was a retrospective pre- vs post-implementation analysis of a discharge process from triage to decrease emergency department length of stay. We implemented a policy that allowed the physician assistant to discharge lower acuity patients directly from triage. We collected daily length of stay metrics for a two-week period prior to and a two-week period after the implementation of the policy. Total and daily pre- and post-implementation length of stay means were compared and reported. Results There was a total of 1044 (pre-implementation) and 1063 (post-implementation) patients evaluated during the study period. There was a significant mean difference improvement in the overall length of stay post-implementation of 18.43 minutes (95% CI, 15.45 - 21.40). When comparing the differences for the day of the week, all days showed a statistically significant mean improvement in the length of stay of greater than 10%. Conclusion Discharging low acuity patients directly from triage can lead to a reduction in length of stay. Future studies are needed to determine the impact of different confounders on the length of stay of patients who are discharged from triage, as well as studies to evaluate the outcomes of patients that have been discharged from triage.

Improving Patient Flow and Decreasing Patient Length of Stay in the Pediatric Emergency Department Through Implementation of a Fast Track

Increased utilization of the emergency department (ED) for low acuity concerns saturates EDs, leading to overcrowding. As the ED becomes crowded, the quality of care threatens patient safety and increases length of stay. To improve the efficiency of evaluation and discharge of low acuity patients in the pediatric ED, a performance improvement project was implemented to develop a Fast Track. An interdisciplinary team developed the process of Fast Track, as well as guidelines for low acuity patients who would be evaluated in the designated area by an advanced practice provider and registered nurse team. Within 14 months of operating, length of stay of low acuity patients triaged an emergency severity illness score of 4 or 5 dropped 36% (from 144 to 92 min). Pediatric patients who present to the ED with low acuity concerns can be effectively and efficiently cared for in a timely fashion in a pediatric ED Fast Track.

Emergency department length of stay following discontinuation of routine oral contrast material

PURPOSE

To determine the effect of discontinuing routine oral contrast material on emergency department (ED) length of stay (LOS), time from order to CT completion, and preliminary report turnaround time (TAT).

METHODS

A HIPAA-compliant, IRB-waived, single-institution, retrospective cohort study was conducted on adult patients presenting with abdominal pain to the ED from October 2015 to April 2019. Routine oral contrast material was administered prior to July 2018 and discontinued thereafter. CT workflow (ED LOS, exam completion time, report TAT) data were analyzed in a univariate analysis before and after discontinuation of oral contrast. Pre- versus post-policy data were compared with 2-sided t tests. The primary outcome was ED LOS. Data were analyzed on a process control chart and confidence limits were adjusted using established criteria.

RESULTS

There were 5020 included abdominopelvic CTs. After routine oral contrast material was discontinued, ED LOS (13.4 h vs 10.7 h, p < 0.001) and time from CT order to CT completion (2.7 h vs 2.1 h, p < 0.001) declined. However, control chart analysis revealed improvement in overall LOS preceded the policy change by 9 months, while improvement in time to CT completion coincided with the policy change. Preliminary report TAT increased by 4 min after the policy change (29 min vs. 33 min, p < 0.001).

CONCLUSIONS

Discontinuation of routine oral contrast material in the ED accelerated time to CT completion but had a minor non-significant effect on overall ED LOS. Much of the reduction in overall LOS likely was due to unrelated process improvements.

Impact of Provider-In-Triage in a Safety-Net Hospital

BACKGROUND

Increasing emergency department (ED) utilization has contributed to ED overcrowding, with longer ED length of stay (EDLOS) and more patients leaving without being seen (LWBS), and is associated with higher morbidity and mortality rates. Previous studies of provider in triage (PIT) have shown decreased LWBS, but variable improvements in EDLOS.

OBJECTIVES

We evaluated the impact of PIT implementation in an urban safety-net hospital on commonly reported ED throughput metrics.

METHODS

This before-and-after study was performed at an academic urban safety hospital. We implemented a PIT team that screened ambulatory ED patients for early discharge or expedited workup. The PIT intervention was implemented 3 days a week from January through April 2019. As controls, we compared throughput metrics from when PIT was unavailable (Group 2) and from 1 year prior (Group 3).

RESULTS

There were significantly (p < 0.001) lower rates of LWBS in Group 1 (4.8%, 95% confidence interval [CI] 4.1-5.8%) compared with 2 (7.3%, 95% CI 5.5-9.7%) and 3 (7.8%, 95% CI 6.9-9.0%). Door-to-doctor times were significantly (p < 0.001) lower for Group 1 (148 min, interquartile range [IQR] 88, 226 min) compared with 2 (187 min, IQR 95.5, 266 min) and 3 (215 min, IQR 131, 290 min). EDLOS was significantly (p < 0.001) shorter for Group 1 (337 min, IQR 215, 468 min) compared with 2 (385 min, IQR 271, 516 min) and 3 (413 min, IQR 299, 538 min).

CONCLUSIONS

We found significantly lower LWBS rates, shorter EDLOS, and shorter door-to-doctor times after PIT implementation. Compared with previous studies in a variety of settings, we found that PIT significantly improved LWBS and all throughput metrics in a safety net setting.

Impact of triage liaison provider on emergency department throughput: A systematic review and meta-analysis

INTRODUCTION

Emergency department (ED) overcrowding is linked to poor outcome and decreases patient satisfaction. Strategies to control Emergency department (ED) overcrowding has been subject of research.

STUDY OBJECTIVES

The objective of this systematic review and meta-analysis was to investigate the impact of triage liaison providers (TLPs) on the ED throughput.

METHODS

We searched PubMed, EMBASE, and Web of Science up to April 2019 for studies done in the United States. Primary outcomes were number of patients left without being seen (LWBS) and patients' emergency department length of stay (ED-LOS). ED-LOS data was pooled using mean difference with random effect model. Risk Ratio (RRs) for LWBS was calculated with random effect model with 95% confidence interval (95% CI).

RESULTS

Twelve studies encompassing 329,340patients were included in the meta-analysis. Implementation of the TLP system using attending physicians was associated with a decrease in risk of LWBS 0.62 (95% CI 0.54, 0.71), The change in ED-LOS after implementation of TLP was too heterogeneous to pool the data with the mean ΔED-LOS ranging from -82 to +20 min. Stratification of studies by disposition, admitted versus discharged, did not decrease the heterogeneity.

CONCLUSION

Implementation of TLP can decrease the rate of LWBS however this review is inconclusive about the effect of TLP on ED-LOS due to the high heterogeneity observed in the literature.

Implementing a Fast-Track Team Triage Approach in Response to Hurricane Maria

BACKGROUND

Hurricane Maria struck Puerto Rico on September 20, 2017, and caused widespread damage to the island, resulting in decreased access to health care. Sixteen days later, a mobile military hospital (MMH) was deployed to Humacao, Puerto Rico, to provide medical relief. Overcrowding in EDs is a problem in disaster relief responses, as was the case here. Initial triage practices resulted in long wait times and limited access to care, and many people left before being seen by a provider.

PURPOSE

This study describes the implementation of a combined fast-track and team triage process to quickly and effectively screen patients in the MMH.

METHODS

In addition to maintaining a formal triage, our ED staff combined two systems, fast track and team triage, to accommodate the influx of patients. This newly combined approach consisted of a health care provider (an MD, NP, or physician assistant) and an RN to facilitate the evaluation, treatment, and discharge of lower-acuity patients.

RESULTS

During peak operations (days 13 to 26 of the total 31 days of operation), 70% of MMH patients were evaluated, treated, and discharged from the combined fast-track and team triage, while only 28% of patients were sent to formal triage; patients with critical conditions (2% of the total) were sent directly to the ED. The mean number of patients seen daily in the first 10 days of operation (n = 84) increased by an average of 48% (n = 124) in the 14 days of peak operations.

CONCLUSION

The combined fast-track and team triage approach enabled us to quickly and effectively screen patients and greatly improved clinical outcomes and patient flow in a mobile facility.

SurgeCon: Priming a Community Emergency Department for Patient Flow Management

Introduction

Canadian emergency departments (ED) are struggling to provide timely emergency care. Very few studies have assessed attempts to improve ED patient flow in the rural context. We assessed the impact of SurgeCon, an ED patient-management protocol, on total patient visits, patients who left without being seen (LWBS), length of stay for departed patients (LOSDep), and physician initial assessment time (PIA) in a rural community hospital ED.

Methods

We implemented a set of commonly used methods for increasing ED efficiency with an innovative approach over 45 months. Our intervention involved seven parts comprised of an external review, Lean training, fast track implementation, patient-centeredness approach, door-to-doctor approach, performance reporting, and an action-based surge capacity protocol. We measured key performance indicators including total patient visits (count), PIA (minutes), LWBS (percentage), and LOSDep (minutes) before and after the SurgeCon intervention. We also performed an interrupted time series (ITS) analysis.

Results

During the study period, 80,709 people visited the ED. PIA decreased from 104.3 (±9.9) minutes to 42.2 (±8.1) minutes, LOSDep decreased from 199.4 (±16.8) minutes to 134.4(±14.5) minutes, and LWBS decreased from 12.1% (±2.2) to 4.6% (±1.7) despite a 25.7% increase in patient volume between pre-intervention and post-intervention stages. The ITS analysis revealed a significant level change in PIA - 19.8 minutes (p<0.01), and LWBS - 3.8% (0.02), respectively. The change over time decreased by 2.7 minutes/month (p< 0.001), 3.0 minutes/month (p<0.001) and 0.4%/month (p<0.001) for PIA, LOSDep, and LWBS, after the intervention.

Conclusion

SurgeCon improved the key wait-time metrics in a rural ED in a country where average wait times continue to rise. The SurgeCon platform has the potential to improve ED efficiency in community hospitals with limited resources.