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Youssef E, Benabbas R, Choe B, Doukas D, Taitt HA, Verma R, Zehtabchi S. Interventions to improve emergency department throughput and care delivery indicators: A systematic review and meta-analysis. Acad Emerg Med 2024; 31:789-804. [PMID: 38826092 DOI: 10.1111/acem.14946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/19/2024] [Accepted: 05/10/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Emergency department (ED) crowding has repercussions on acute care, contributing to prolonged wait times, length of stay, and left without being seen (LWBS). These indicators are regarded as systemic shortcomings, reflecting a failure to provide equitable and accessible acute care. The objective was to evaluate the effectiveness of interventions aimed at improving ED care delivery indicators. METHODS This was a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing ED interventions aimed at reducing key metrics of time to provider (TTP), time to disposition (TTD), and LWBS. We excluded disease-specific trials (e.g., stroke). We used Cochrane's revised tool to assess the risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations to rate the quality of evidence. The meta-analysis was performed using a random-effects model and Cochrane Q test for heterogeneity. Data were summarized as means (±SD) for continuous variables and risk ratios (RR) with 95% confidence intervals (CIs). RESULTS We searched MEDLINE, EMBASE, and other major databases. A total of 1850 references were scanned and 20 RCTs were selected for inclusion. The trials reported at least one of the three outcomes of TTD, TTP, or LWBS. Most interventions focused on triage liaison physician and point-of-care (POC) testing. Others included upfront expedited workup (ordering tests before full evaluation by a provider), scribes, triage kiosks, and sending notifications to consultants or residents. POC testing decreased TTD by an average of 5-96 min (high heterogeneity) but slightly increased TTP by a mean difference of 2 min (95% CI 0.6-4 min). Utilizing a triage liaison physician reduced TTD by 28 min (95% CI 19-37 min; moderate-quality evidence) and was more effective in reducing LWBS than routine triage (RR 0.76, 95% CI 0.66-0.88; moderate quality). CONCLUSIONS Operational strategies such as POC testing and triage liaison physicians could mitigate the impact of ED crowding and appear to be effective. The current evidence supports these strategies when tailored to the appropriate practice environment.
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Affiliation(s)
- Elias Youssef
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Roshanak Benabbas
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Brittany Choe
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Donald Doukas
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Hope A Taitt
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Rajesh Verma
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Shahriar Zehtabchi
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
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Janerka C, Leslie GD, Gill FJ. Patient experience of emergency department triage: An integrative review. Int Emerg Nurs 2024; 74:101456. [PMID: 38749231 DOI: 10.1016/j.ienj.2024.101456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 04/07/2024] [Accepted: 04/26/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Emergency department (ED) triage is often patients' first contact with a health service and a critical point for patient experience. This review aimed to understand patient experience of ED triage and the waiting room. METHODS A systematic six-stage approach guided the integrative review. Medline, CINAHL, EmCare, Scopus, ProQuest, Cochrane Library, and JBI database were systematically searched for primary research published between 2000-2022 that reported patient experience of ED triage and/or waiting room. Quality was assessed using established critical appraisal tools. Data were analysed for descriptive statistics and themes using the constant comparison method. RESULTS Twenty-nine articles were included. Studies were mostly observational (n = 17), conducted at a single site (n = 23), and involved low-moderate acuity patients (n = 13). Nine interventions were identified. Five themes emerged: 'the who, what and how of triage', 'the patient as a person', 'to know or not to know', 'the waiting game', and 'to leave or not to leave'. CONCLUSION Wait times, initiation of assessment and treatment, information provision and interactions with triage staff appeared to have the most impact on patient experience, though patients' desires for each varied. A person-centred approach to triage is recommended.
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Affiliation(s)
- Carrie Janerka
- School of Nursing, Curtin University, Western Australia, Australia; Fiona Stanley Hospital, South Metropolitan Health Service, Western Australia, Australia.
| | - Gavin D Leslie
- School of Nursing, Curtin University, Western Australia, Australia
| | - Fenella J Gill
- School of Nursing, Curtin University, Western Australia, Australia; Perth Children's Hospital, Child and Adolescent Health Service, Western Australia, Australia
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Samadbeik M, Staib A, Boyle J, Khanna S, Bosley E, Bodnar D, Lind J, Austin JA, Tanner S, Meshkat Y, de Courten B, Sullivan C. Patient flow in emergency departments: a comprehensive umbrella review of solutions and challenges across the health system. BMC Health Serv Res 2024; 24:274. [PMID: 38443894 PMCID: PMC10913567 DOI: 10.1186/s12913-024-10725-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/14/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Globally, emergency departments (EDs) are overcrowded and unable to meet an ever-increasing demand for care. The aim of this study is to comprehensively review and synthesise literature on potential solutions and challenges throughout the entire health system, focusing on ED patient flow. METHODS An umbrella review was conducted to comprehensively summarise and synthesise the available evidence from multiple research syntheses. A comprehensive search strategy was employed in four databases alongside government or organisational websites in March 2023. Gray literature and reports were also searched. Quality was assessed using the JBI critical appraisal checklist for systematic reviews and research syntheses. We summarised and classified findings using qualitative synthesis, the Population-Capacity-Process (PCP) model, and the input/throughput/output (I/T/O) model of ED patient flow and synthesised intervention outcomes based on the Quadruple Aim framework. RESULTS The search strategy yielded 1263 articles, of which 39 were included in the umbrella review. Patient flow interventions were categorised into human factors, management-organisation interventions, and infrastructure and mapped to the relevant component of the patient journey from pre-ED to post-ED interventions. Most interventions had mixed or quadruple nonsignificant outcomes. The majority of interventions for enhancing ED patient flow were primarily related to the 'within-ED' phase of the patient journey. Fewer interventions were identified for the 'post-ED' phase (acute inpatient transfer, subacute inpatient transfer, hospital at home, discharge home, or residential care) and the 'pre-ED' phase. The intervention outcomes were aligned with the aim (QAIM), which aims to improve patient care experience, enhance population health, optimise efficiency, and enhance staff satisfaction. CONCLUSIONS This study found that there was a wide range of interventions used to address patient flow, but the effectiveness of these interventions varied, and most interventions were focused on the ED. Interventions for the remainder of the patient journey were largely neglected. The metrics reported were mainly focused on efficiency measures rather than addressing all quadrants of the quadruple aim. Further research is needed to investigate and enhance the effectiveness of interventions outside the ED in improving ED patient flow. It is essential to develop interventions that relate to all three phases of patient flow: pre-ED, within-ED, and post-ED.
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Affiliation(s)
- Mahnaz Samadbeik
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Brisbane, Australia.
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia.
| | - Andrew Staib
- Princess Alexandra Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Justin Boyle
- The Australian E-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Australia
| | - Sankalp Khanna
- The Australian E-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Australia
| | - Emma Bosley
- Queensland Ambulance Service, Queensland Government, Brisbane, Australia
| | - Daniel Bodnar
- Queensland Ambulance Service, Queensland Government, Brisbane, Australia
| | - James Lind
- Gold Coast University Hospital, Gold Coast, Australia
| | - Jodie A Austin
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Sarah Tanner
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Yasaman Meshkat
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Barbora de Courten
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
| | - Clair Sullivan
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Faculty of Medicine, Queensland Digital Health Centre, The University of Queensland, Brisbane, QLD, 4072, Australia
- Department of Health, Metro North Hospital and Health Service, Brisbane, Australia
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
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Crowder K, Domm E, Lipp R, Robinson O, Vatanpour S, Wang D, Lang E. The multicenter impacts of an emergency physician lead on departmental flow and provider experiences. CAN J EMERG MED 2023; 25:224-232. [PMID: 36790639 DOI: 10.1007/s43678-023-00459-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 01/13/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Emergency department (ED) flow impacts patient safety, quality of care and ED provider satisfaction. Throughput interventions have been shown to improve flow, yet few studies have reported the impact of ED physician leadership roles on patient flow and provider experiences. The study objective was to evaluate the impacts of the emergency physician lead role on ED flow metrics and provider experiences. METHODS Quantitative data about patient flow metrics were collected from ED information systems in two tertiary hospital EDs and analyzed to compare ED length of stay, EMS hallway length of stay, physician initial assessment time, 72-h readmission and left without being seen rates three months before and following emergency physician lead role implementation. ED flow metrics for adult patients at each site were analyzed independently using descriptive and inferential statistics, t tests and multivariable regression analysis. Qualitative data were collected via surveys from ED providers (physicians, nurses, and EMS) about their experiences working with the emergency physician leads and analyzed for themes about emergency physician leads impact. RESULTS The number of ED visits was relatively stable pre-post at the Peter Lougheed Centre (Lougheed) but increased pre-post at the Foothills Medical Centre (Foothills). Post-intervention at Lougheed median ED length of stay decreased by 18 min (p < 0.001) and at Foothills ED length of stay increased by 8 min (p < 0.001). EMS length of stay at Lougheed decreased by 20 min (p < 0.001), and at Foothills length of stay increased by 17 min (p < 0.001). Themes in provider feedback were that emergency physician leads (1) facilitated patient flow, (2) impacted provider workload, and (3) supported patient flow and safety with early assessments, treatments and investigations. CONCLUSION In this study, the emergency physician lead impacted ED flow metrics variably at different sites, but important learnings from provider experiences can guide future emergency physician lead implementation.
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Affiliation(s)
- Kathryn Crowder
- Department of Emergency Medicine, Alberta Health Services, Calgary, AB, Canada. .,University of Calgary Cumming School of Medicine, Calgary, AB, Canada.
| | - Elizabeth Domm
- Faculty of Nursing, University of Regina, Regina, SK, Canada
| | - Rachel Lipp
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Owen Robinson
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Shabnam Vatanpour
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Dongmei Wang
- Department of Emergency Medicine, Alberta Health Services, Calgary, AB, Canada
| | - Eddy Lang
- Department of Emergency Medicine, Alberta Health Services, Calgary, AB, Canada.,University of Calgary Cumming School of Medicine, Calgary, AB, Canada
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Loch T, Elzinga J, Polsky Z, Lang E, Patocka C. Realist inquiry: a new way to think about overcrowding interventions. CAN J EMERG MED 2022; 24:434-438. [PMID: 35378722 DOI: 10.1007/s43678-022-00287-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Physician-focused throughput initiatives are intended to mitigate the effects of emergency department (ED) overcrowding. Our tertiary care academic hospital recently piloted an emergency physician leader role intended to improve throughput. Although a separate experimental evaluation of this initiative was undertaken, it was expected that such an evaluation could not alone provide the necessary information to inform 'how' the emergency physician leader intervention worked. The objective of this study was to conduct a realist evaluation of the emergency physician leader. Realist inquiry utilizes Context Mechanism Outcome configurations to determine the impacts of interventions that are often missed by quantitative analysis. Using a realist perspective, this study aimed to evaluate the emergency physician leader initiative's effects on throughput with the goal of building transferable lessons to the implementation of future interventions. METHODS Semi-structured interviews with key stakeholders in the intervention were conducted and analyzed using thematic and template techniques specifically aimed at identifying Context Mechanism Outcomes. RESULTS 13 interviews were conducted with physicians and nurses who identified contexts and mechanisms which promoted or impeded ED throughput. For example, in situations where there was a clear indication for imaging or management that could not be initiated within the scope of a nursing protocol, the emergency physician leader initiating these orders was felt to promote ED throughput. Conversely, in contexts where there was no nurse available to fulfill early orders, the emergency physician leader's initiation of orders was perceived to impede throughput. CONCLUSION This evaluation provides insights into the reasoning and behaviour of individuals involved in the emergency physician leader initiative and provides a systematic approach to unraveling its complex causal pathway. Knowledge of context-mechanism-outcome relationships may help implementers design and measure the impact of future physician-focused throughput interventions.
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Affiliation(s)
- Tess Loch
- Cumming School of Medicine, University of Calgary, C-231 1403-29St NW, Calgary, AB, T2N 2T9, Canada.
| | - Jason Elzinga
- Cumming School of Medicine, University of Calgary, C-231 1403-29St NW, Calgary, AB, T2N 2T9, Canada
| | - Zoe Polsky
- Cumming School of Medicine, University of Calgary, C-231 1403-29St NW, Calgary, AB, T2N 2T9, Canada
| | - Eddy Lang
- Cumming School of Medicine, University of Calgary, C-231 1403-29St NW, Calgary, AB, T2N 2T9, Canada
| | - Catherine Patocka
- Cumming School of Medicine, University of Calgary, C-231 1403-29St NW, Calgary, AB, T2N 2T9, Canada
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Patient Throughput Initiatives in Ambulatory Care Organizations during the COVID-19 Pandemic: A Systematic Review. Healthcare (Basel) 2021; 9:healthcare9111474. [PMID: 34828520 PMCID: PMC8624418 DOI: 10.3390/healthcare9111474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/20/2021] [Accepted: 10/27/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Ambulatory (outpatient) health care organizations continue to respond to the COVID-19 global pandemic using an array of initiatives to provide a continuity of care for both COVID-19 and non-COVID-19 patients. The purpose of this study is to systematically identify the facilitators and barriers experienced by outpatient health care organizations in an effort to maintain effective and efficient patient throughput during the pandemic. MATERIALS AND METHODS This study systematically reviewed articles focused on initiatives taken by ambulatory care organizations to maintain optimal outpatient throughput levels while balancing pandemic precautions, published during 2020. RESULTS Among the 30 articles that met the inclusion criteria, three initiatives healthcare organizations have taken to maintain throughput were identified: the use (and enhanced use) of telehealth, protocol development, and health care provider training. The research team also identified three barriers to patient throughput: lack of telehealth, lack of resources, and overall lack of knowledge. CONCLUSIONS To maintain patient throughput during the COVID-19 pandemic, healthcare organizations need to develop strategies such as the use of virtual consultation and follow-up, new guidelines to move patients along the care delivery value-chain, and ongoing training of providers. Additionally, the availability of required technology for telehealth, availability of resources, and adequate knowledge are vital for continuous patient throughput to ensure continuity of care during a pandemic.
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The Other Side of Immediate Bedding: A Call to Action to the Research Community. J Emerg Nurs 2021; 47:529-530. [PMID: 34275525 DOI: 10.1016/j.jen.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 11/29/2022]
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Franklin BJ, Li KY, Somand DM, Kocher KE, Kronick SL, Parekh VI, Goralnick E, Nix AT, Haas NL. Emergency department provider in triage: assessing site-specific rationale, operational feasibility, and financial impact. J Am Coll Emerg Physicians Open 2021; 2:e12450. [PMID: 34085053 PMCID: PMC8144283 DOI: 10.1002/emp2.12450] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/09/2021] [Accepted: 04/22/2021] [Indexed: 11/18/2022] Open
Abstract
Emergency department (ED) crowding is recognized as a critical threat to patient safety, while sub-optimal ED patient flow also contributes to reduced patient satisfaction and efficiency of care. Provider in triage (PIT) programs-which typically involve, at a minimum, a physician or advanced practice provider conducting an initial screening exam and potentially initiating treatment and diagnostic testing at the time of triage-are frequently endorsed as a mechanism to reduce ED length of stay (LOS) and therefore mitigate crowding, improve patient satisfaction, and improve ED operational and financial performance. However, the peer-reviewed evidence regarding the impact of PIT programs on measures including ED LOS, wait times, and costs (as variously defined) is mixed. Mechanistically, PIT programs exert their effects by initiating diagnostic work-ups earlier and, sometimes, by equipping triage providers to directly disposition patients. However, depending on local contextual factors-including the co-existence of other front-end interventions and delays in ED throughput not addressed by PIT-we demonstrate how these features may or may not ultimately translate into reduced ED LOS in different settings. Consequently, site-specific analysis of the root causes of excessive ED LOS, along with mechanistic assessment of potential countermeasures, is essential for appropriate deployment and successful design of PIT programs at individual EDs. Additional motivations for implementing PIT programs may include their potential to enhance patient safety, patient satisfaction, and team dynamics. In this conceptual article, we address a gap in the literature by demonstrating the mechanisms underlying PIT program results and providing a framework for ED decision-makers to assess the local rationale for, operational feasibility of, and financial impact of PIT programs.
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Affiliation(s)
| | - Kathleen Y. Li
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMichiganUSA
- Department of Emergency MedicineMichigan MedicineAnn ArborMichiganUSA
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - David M. Somand
- Department of Emergency MedicineMichigan MedicineAnn ArborMichiganUSA
- Division of Emergency Critical CareMichigan MedicineAnn ArborMichiganUSA
| | - Keith E. Kocher
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMichiganUSA
- Department of Emergency MedicineMichigan MedicineAnn ArborMichiganUSA
| | - Steven L. Kronick
- Department of Emergency MedicineMichigan MedicineAnn ArborMichiganUSA
| | - Vikas I. Parekh
- Department of Internal MedicineMichigan MedicineAnn ArborMichiganUSA
| | - Eric Goralnick
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - A. Tyler Nix
- Taubman Health Sciences LibraryUniversity of MichiganAnn ArborMichiganUSA
| | - Nathan L. Haas
- Department of Emergency MedicineMichigan MedicineAnn ArborMichiganUSA
- Division of Emergency Critical CareMichigan MedicineAnn ArborMichiganUSA
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