A Comparison of Wait Times and Patients Leaving Without Being Seen When Licensed Nurses Versus Unlicensed Assistive Personnel Perform Triage

Emergency department responses to nursing shortages

BACKGROUND

The COVID-19 pandemic exacerbated the nursing shortage, which is predicted to continue to worsen with significant numbers of nurses planning to retire within the next 5 years. There remains a lack of published information regarding recommended interventions for emergency departments (EDs) facing a sudden nursing shortage.

METHODS

We queried emergency department leaders from the American College of Emergency Physicians to examine the impact of nursing shortages on EDs and to gather real-world interventions employed to mitigate the effects of the shortage.

RESULTS

Most respondents (98.5%) reported nursing shortages, with 83.3% describing prolonged shortages lasting more than 12 months, with negative impacts such as misses/near-misses (93.9%) and increasing left without being seen rates (90.9%). ED leaders reported a range of interventions, including operational flow changes, utilizing alternative staff to fill nurse roles, recruitment of new nurses, and retention strategies for existing nurses. They employed temporary and permanent pay increases as well as efforts to improve the ED work environment and techniques to hire new nurses from atypical pipelines.

CONCLUSION

We report a patchwork of solutions ED leaders utilized which may have variable efficacy among different EDs; personalization is essential when selecting interventions during a sudden nursing shortage.

Investigation of the usability of the REMS, RAPS, and MPM II0 scoring systems in the prediction of short-term and long-term mortality in patients presenting to the emergency department triage

BACKGROUND

Appropriate triage is an important component of patient management in emergency departments. The risk scoring system used for triage purposes in emergency departments should be obtained quickly and based on parameters directly related to prognosis.

AIMS

To investigate the success of the Rapid Emergency Medicine Score (REMS) and Rapid Acute Physiology Score (RAPS) as triage scoring systems and the Mortality Probability Model (MPM II₀) as an intensive care scoring system in identifying critical patients visited to the emergency department (ED) triage and predicting mortality, and to evaluate their superiority over each other, if any.

METHODS

This research was planned as a single-center and prospectively. The data of the study were obtained by screening the medical records of all patients who presented to the ED triage between January 1, 2020 and January 31, 2020. Patients under the age of 18 years, those with missing information in their files and pregnant women were not included in the study. Only the patients for whom the REMS, RAPS, and MPM II₀ scores could be calculated were included in the sample.

RESULTS

After excluding the patients who did not meet the inclusion criteria, the study was completed with 12,210 patients. The mean age of these patients was 44.7 ± 18.7 years, and 47.3% were male. The area under the receiver operating characteristics curve values for the prediction of 24-h, 30-day, 90-day, and 180-day mortality were determined as 0.979, 0.921, 0.904, and 0.897, respectively, for REMS; 0.929, 0.778, 0.75, and 0.725, respectively, for RAPS; and 0.925, 0.888, 0.866, and 0.861, respectively, for MPM II₀.

CONCLUSIONS

In this study, it was concluded that the REMS score was superior to the MPM II₀ and RAPS scores in predicting the short-term and long-term mortality status of patients and determining the discharge and hospitalization status of the patients.

A quantitative systematic review of the association between nurse skill mix and nursing-sensitive patient outcomes in the acute care setting

AIMS

To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.

DESIGN

A quantitative systematic review included studies published in English between January 2000 - September 2018.

DATA SOURCES

Cochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix-methods designs were included if the quantitative component met the criteria.

REVIEW METHODS

The Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy-five percent or more of studies with significant results found this association.

RESULTS

Sixty-three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure-to-rescue; pneumonia; sepsis; urinary tract infection; mortality/30-day mortality; pressure injury; infections and shock/cardiac arrest/heart failure.

CONCLUSION

Nursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes.

IMPACT

Skill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.

Trauma Team Activation: Accuracy of Triage When Minutes Count: A Synthesis of Literature and Performance Improvement Process

Accuracy and timeliness of trauma activations are vital to patient safety. The American College of Surgeons mandates the trauma surgeon's presence within 15 min of the patient's arrival to the emergency department (ED) 80% of the time. In 2015, at this Level II Pediatric Trauma Center, average mean activation times were approximately 16 min and activation accuracy (over- and undertriage) affected 27% of the trauma patient activations. This evidence-based quality improvement project set out to determine the most efficient method of Emergency Medical Services (EMS) intake. Communication Center (Com. Center) recordings were carefully reviewed to identify time when EMS notifies the Com. Center and actual time of trauma activation page. A timeline was formulated with assessment of time to activation and patient triage accuracy. An educational curriculum was developed as an intervention for the Com. Center staff. Education included a decision tree for trauma activations and the development of templates for our electronic health record and prompts to improve accurate activations. After additional focus groups analyzed present ED performance and the industry standard, a policy requiring only paramedic-trained staff was put in place. After implementation of the aforementioned intervention, the Com. Center performance revealed reduction in incorrect activations from 27.3% to 10.7% from 2015 to 2016. Mean activation time in January 2015 was 48.5 min before the intervention and 4.71 min postintervention in December 2016; this is a staggering reduction in activation times of 90%!

Effectiveness of Five-Level Emergency Severity Index Triage System Compared With Three-Level Spot Check: An Iranian Experience

Background:

Triage for patients’ prioritization in the emergency department is a suitable solution to decrease overcrowding. Different methods are used for prioritization that needs effectiveness evaluation.

Objectives:

The aim of this study was to assess the effectiveness of the emergency severity index (ESI) 5-level triage system in contrast with spot check triage.

Patients and Methods:

Data for this quasi-experimental study were extracted using a form to review 770 records of patients referred to emergency department of Imam Khomeini hospital (in Sari, north of Iran) during two separated periods each for four months; the first from 20th March to 19th July 2010 and the other from 21 March to 20 July 2011. The method used in the first time was spot check triage and the second one ESI triage. Data were processed with descriptive statistics and analyzed using independent samples t-test (CI = 95%).

Results:

Increase from 6.46 to 8.92 minutes in the average time from patient arrival to being visited by a physician (P < 0.001) and increase in average time from physician visit to receive the first nursing care from 7.68 to 15.89 minutes were significant (P < 0.001). The average waiting time for laboratory services was significantly decreased from 112.3 to 84.1 (P = 0.033). Increase in the average waiting time for radiology, decrease in average waiting time for sonography, average length of stay in the emergency department, and number of patients per emergency bed were not significant.

Conclusions:

Between the two systems of triage, ESI was more effective than the spot check and in the spatial and temporal domain of research, was a successful method in improving some indicators of emergency and improving the performance indices. Hospital managers by implementation of ESI system can take a step toward new health policies and improve the processes as key tools of continuous quality improvement system.

Measuring and Analyzing Waiting Time Indicators of Patients' Admitted in Emergency Department: A Case Study

Background & Aims:

Measuring and analyzing of provided services times in Emergency Department is the way to improves quality of hospital services. The present study was conducted with aim measuring and analyzing patients waiting time indicators in Emergency Department in a general hospital in Iran.

Material & Methods:

This cross-sectional, observational study was conducted during April to September 2012. The study population consisted of 72 patients admitted to the Emergency Department at Baharlo hospital. Data collection was carried out by workflow forms. Data were analyzed by t. test and ANOVA.

Results:

The average waiting time for patients from admission to enter the triage 5 minutes, the average time from triage to physician visit 6 minute and the average time between examinations to leave ED was estimated 180 minutes. The total waiting time in the emergency department was estimated at about 210 minutes. The significant correlation between marital status of patients (P=0.03), way of arrive to ED (P=0.02) and type of shift work (P=0.01) with studied time indicators were observed.

Conclusion:

According to results and comparing with similar studies, the average waiting time of patients admitted to the studied hospital is appropriate. Factors such as: Utilizing clinical governance system and attendance of resident Emergency Medicine Specialist have performed an important role in reducing of waiting times in ED.

Telephone triage assessment for musculoskeletal disorders: part 1

Changes in the delivery of occupational health and wellbeing services can affect the employer, employees and service users. Despite the impact of such changes, many organisations implement them without understanding their true effects. Support of staff and service users is needed if change is to be implemented and services reconfigured to improve overall efficiency. A diagnostic analysis has been recommended as a precursor to assess what impact a change would have. This paper explores the process of a diagnostic analysis before nursing telephone triage assessment for musculoskeletal disorders was implemented in an occupational health and wellbeing service. Mixed methods were used to gather the relevant information.

Do triage systems in healthcare improve patient flow? A systematic review of the literature

OBJECTIVES

Triage processes are often used by Emergency Departments to sort patients according to urgency or type of service required. Triage may also be used in a broad spectrum of other health services and not just emergency departments. Triage systems may be used to ensure the most urgent patients get timely service, but do they have an effect on patient flow?

METHODS

We conducted a systematic review by searching five electronic databases (until August 2009) combining the elements 'triage' and 'patient flow', complemented by hand searching reference lists and citation tracking. We identified and assessed the quality of 25 articles that met inclusion criteria. Population, setting, design and results were extracted and a process of descriptive synthesis applied. Effect sizes for waiting time were compared for seven studies in which sufficient data could be extracted.

RESULTS AND CONCLUSION

Moderate evidence exists from a range of health services that the ability to combine triage and initial treatment in less resource intensive cases can have a positive effect on patient flow. There is conflicting evidence that triage systems that only prioritize patients, without providing any treatment, improve overall patient flow, although tailoring triage criteria more specifically to the patient population or using triage to prioritize treatable cases may be of benefit.

"Be quick": a systems response to overcrowding in the pediatric emergency department

OBJECTIVE

The purpose of this study was to evaluate the combined effects of focused system changes on several key measures of emergency department (ED) quality (length of stay, waiting time, rate of leaving without being seen, and patient satisfaction) in a children's hospital ED.

METHODS

System-wide ED changes were made and implemented during a 6-month period. The combined changes are called "be quick"--BEQK. The components were bedside registration, the Bed-ahead program, electronic medical records and tracking board, quick triage, and Kids Express. Three study periods were evaluated: before BEQK (2005) and the 2 periods after BEQK (2006 and 2007).

RESULTS

The primary outcome measures, namely wait time, length of stay, and leaving without being seen rates, were all decreased during the 2 post-BEQK periods compared with the pre-BEQK period (2005). The mean waiting time was 46 minutes (95% confidence interval [CI], 39-53 minutes) in 2005 and this decreased to 22 minutes (95% CI, 21-23 minutes) and 14 minutes (95% CI, 13-15 minutes) in 2006 and 2007, respectively. The mean length of stay was 151 minutes (95% CI, 139-163 minutes) in 2005 and this decreased to 136 minutes (95% CI, 135-137 minutes) and 115 minutes (95% CI, 114-116 minutes) in 2006 and 2007, respectively. The rate of leaving without being seen was 2.45% of patient visits per month in 2005 and this decreased to 1.67% in 2006 and to 0.92% in 2007.

CONCLUSIONS

In our pediatric ED, focused system changes significantly decreased wait time, leaving without being seen, and length of stay and improved patient satisfaction.

Patients who leave the emergency department without being seen

INTRODUCTION

Patients who present to the ED for care and leave without being seen (LWBS) represent a significant problem. The objective of this study was to determine why patients LWBS, how long they perceived waiting versus actual time waited before leaving, and factors that might have prevented LWBS.

METHODS

We conducted a prospective, scripted phone survey of all patients who left without being seen over a two-month period in 2006 at an ED with approximately 65,000 yearly visits. Outcome measures were number leaving, ability to obtain care after leaving, reason for leaving, would they return to this ED, perceived and actual time waited, number with a primary physician, and factors associated with leaving.

RESULTS

One-hundred and twenty-seven of 11,147 total patients (1.1%) patients left without being seen. Seventy-two (56.7%) were interviewed within 8 days. Eighty-four and seven-tenths percent stated they had a primary physician. The mean age was 29.9 years, and 44.4% were male. The patient-reported mean time waited before leaving was 73.2 minutes while the actual mean time waited was 70.4 minutes. The reasons for leaving were the length of wait (76.7%), the problem resolved (12.3%), and for other reasons (11.0%). During the week after leaving the ED, 56.3% were able to obtain medical care. Sixty-five percent would seek future emergency care at this ED, 15.3% would not, and 19.7% would possibly return. During the wait, patients wanted information, lab tests/X-rays, and analgesics.

DISCUSSION

Most would return for future ED care. Most had a physician and were able to obtain care elsewhere. Reduced LWBS might be accomplished by triage testing, communication and attention to pain.

Factors that affect the flow of patients through triage

OBJECTIVE

To use observational methods to objectively evaluate the organisation of triage and what issues may affect the effectiveness of the process.

DESIGN

A two-phase study comprising observation of 16 h of triage in a London hospital emergency department and interviews with the triage staff to build a qualitative task analysis and study protocol for phase 2; observation and timing in triage for 1870 min including 257 patients and for 16 different members of the triage staff.

RESULTS

No significant difference was found between grades of staff for the average triage time or the fraction of time absent from triage. In all, 67% of the time spent absent from triage was due to escorting patients into the department. The average time a patient waited in the reception before triage was 13 min 34 s; the average length of time to triage for a patient was 4 min 17 s. A significant increase in triage time was found when patients were triaged to a specialty, expected by a specialty, or were actively "seen and treated" in triage. Protocols to prioritise patients with potentially serious conditions to the front of the queue had a significantly positive effect on their waiting time. Supplementary tasks and distractions had varying effects on the timely assessment and triage of patients.

CONCLUSIONS

The human factors method is applicable to the triage process and can identify key factors that affect the throughput at triage. Referring a patient to a specialty at triage affects significantly the triage workload; hence, alternative methods or management should be suggested. The decision to offer active treatment at triage increases the time taken, and should be based on clinical criteria and the workload determined by staffing levels. The proportion of time absent from triage could be markedly improved by support from porters or other non-qualified staff, as well as by proceduralised handovers from triage to the main clinical area. Triage productivity could be improved by all staff by becoming aware of the effect of the number of interruptions on the throughput of patients.

Evaluation of the Accuracy of Height Assessment of Premenopausal and Menopausal Women

OBJECTIVE

To assess the accuracy of linear measurement of premenopausal and menopausal women.

DESIGN

Observational.

SETTING

OB/GYN practice in a university setting.

PARTICIPANTS

OB/GYN staff responsible for obtaining linear measurements.

MAIN OUTCOME MEASURES

Equipment utilized, technique for obtaining linear measurement, accuracy of linear measurement.

RESULTS

A research assistant observed six measurers measuring 64 women. Ninety four percent of measurements were inaccurate (p<.001) when compared to those of the research assistant. Measurements differed by as much as 18 cm from the research assistant (M=6.4 cm). Measurements obtained by measurers with more than 10 years of experience were significantly closer to the research assistant measurements than those obtained by less experienced measurers.

CONCLUSIONS

Inaccurate equipment, incorrect technique, and staff inexperience all contributed significantly to inaccuracy of linear measurement in a GYN practice. Correct equipment and staff education are needed. Accurate linear measurements must be obtained to allow for valid clinical decisions regarding the need for hormone replacement therapy based on loss of stature of menopausal women.

Effect of educational preparation on the accuracy of linear growth measurement in pediatric primary care practices: results of a multicenter nursing study

Consistently monitoring a child's linear growth is one of the least invasive, most sensitive tools to identify normal physiologic functioning and a healthy lifestyle. However, studies, mostly from the United Kingdom, indicate that children are frequently measured incorrectly. Inaccurate linear measurements may result in some children having undetected growth disorders whereas others with normal growth being referred for costly, unwarranted specialty evaluations. This study presents the secondary analysis of a primary study that used a randomized control study design to demonstrate that a didactic educational intervention resulted in significantly more children being measured accurately within eight pediatric practices. The secondary analysis explored the influence of the measurer's educational level on the outcome of accurate linear measurement. Results indicated that RNs were twice as likely as non-RNs to measure children accurately.