Health Care Provider in Triage to Improve Outcomes

Submandibular Sialolithiasis Mimicking Ludwig's Angina: A Case Report and Brief Clinical Review

The "double tongue sign" is a characteristic finding in patients with Ludwig's angina, a potentially life-threatening infection due to airway compromise. Management primarily focuses on early airway protection and antibiotic administration. Submandibular sialolithiasis, on the other hand, could present with the double tongue sign without symptoms suggestive of airway involvement. Unlike Ludwig's angina, conservative treatment is usually the first-line approach for sialolithiasis. The importance of rapidly recognizing and distinguishing between the 2 conditions is emphasized through effective triage and risk stratification, particularly in rural areas where physicians are not readily available.

Emergency Department Length of Stay: A Community Hospital Initiative

OBJECTIVE

This quality improvement initiative was conducted to determine if a provider in triage and split flow model could decrease the length of stay (LOS) of discharged patients seen in a community hospital emergency department (ED).

BACKGROUND

Extended LOSs within the ED lead to delays in the care of patients, increase the number of patients who leave without being seen by a provider, decrease patient satisfaction, and cause a loss of revenue for health care organizations. Using a provider in triage and a split flow model, where patients can be seen and dispositioned without delays, can improve ED throughput and decrease the overall LOS.

METHODS

Through a structured, interdisciplinary approach using the Plan-Do-Study-Act Shewhart Cycle of Process Improvement, a provider was placed in triage, and an interior waiting room was used to evaluate emergency severity index level 3 and 4 patients to expedite diagnostic testing and perform procedures. This model allowed lower acuity patients to be cared for separately from higher acuity patients, who were being treated in the main ED. In addition, the median arrival to provider, arrival to bed, and LOS from arrival to departure of discharged patients were compared to the current departmental processes.

RESULTS

There was a significant improvement in the LOS of discharged patients and the time of arrival to triage, arrival to bed, and arrival to provider using a provider in triage and a split flow model compared to the current intake.

CONCLUSION

Implementation of a provider in triage and a split flow model can demonstrate a decrease in the LOS of discharged patients along with other ED metrics and improve efficiencies in patient care within a community hospital.

Novel Electronic Health Records-Based Consultation Workflow Improves Time to Operating Room for Vascular Surgery Patients in an Acute Setting

BACKGROUND

Inefficient clinical workflows can have downstream effects of increased costs, poor resource utilization, and worse patient outcomes. The surgical consultation process can be complex with unclear communication, potentially delaying care for patients requiring time-sensitive intervention in an acute setting. A novel electronic health records (EHR)-based workflow was implemented to improve the consultation process. After implementation, we assessed the impact of this initiative in patients requiring vascular surgery consultation.

METHODS

An EHR-driven consultation workflow was implemented at a single institution, standardizing the process across all consulting services. This order-initiated workflow automated notification to clinicians of consult requests, communication of patient data, patient addition to consultants' lists, and tracking consult completion. Preimplementation (1/1/2020-1/31/2022) and postimplementation (2/1/2022-12/4/2022) vascular surgery consultation cohorts were compared to evaluate the impact of this initiative on timeliness of care.

RESULTS

There were 554 inpatient vascular surgery consultations (255 preimplementation and 299 postimplementation); 45 and 76 consults required surgery before and after implementation, respectively. The novel workflow resulted in placement of a consult note 32 min faster than preimplementation (preimplementation: 462 min, postimplementation: 430 min, P = 0.001) for all vascular surgery consults. Furthermore, vascular surgery patients with ASA class III or IV status requiring an urgent or emergent operation were transported to the operating room 63.3% faster after implementation of the workflow (preimplementation: 284 min, postimplementation: 180 min, P = 0.02). There were no differences in procedure duration, postoperative disposition, or intraoperative complication rates.

CONCLUSIONS

We implemented a novel workflow utilizing the EHR to standardize and automate the consultation process in the acute inpatient setting. This institutional initiative significantly improved timeliness of care for vascular surgery patients, including decreased time to operation. Innovations such as this can be further disseminated across shared EHR platforms across institutions, representing a powerful tool to increase the value of care in vascular surgery and healthcare overall.

Effect of triage training on nurses' practice and triage outcomes of patients with acute coronary syndrome

BACKGROUND

Accurate assessment and prompt management of patients with acute coronary syndrome (ACS) is a complex process for emergency department (ED) nurses and has variable clinical outcomes. The aim of the present study was to determine the effectiveness of an educational intervention on nurses' practice during the triage of patients with ACS and the triage outcomes in this group of patients.

METHODS

In this quasi-experimental study, a pretest-posttest group of 24 nurses were included by convenience sampling method and 960 patients with ACS were selected by sequential sampling during the pre-intervention (n = 480) and post-intervention (n = 480) phases. A case-based learning (CBL) intervention was performed for nurses for one month considering the role of the triage nurse according to the American College of Cardiology (ACC) and the American Heart Association (AHA) recommendations as well as the factors affecting the proper identification and management of patients with ACS. During patient triage in the pre- and post-intervention phases, the "Triage Nurse Practice Checklist" and the "Medical Electronic Records" were used to assess nurses' practice and the triage outcomes in patients, respectively.

RESULTS

The overall mean score of the triage nurses' practice and its subscales, including Primary monitoring and assessment, cardiovascular risk factors assessment, evaluation of coronary heart disease (CHD) symptoms, chest pain management, and adherence to the ACC/AHA practice guidelines were significantly improved in the post-intervention phase compared with the pre-intervention phase (p < 0.001). There was no significant difference between the triage outcomes, including in-hospital mortality within 24 hours, death in ED, hospitalization in other wards, and discharge from ED in the pre and post-intervention phases (P = 0.723).

CONCLUSION

The development of a cardiac triage-specific educational program could improve the performance of nurses in the evaluation and management of patients with ACS, but had no effect on the triage outcomes in this group of patients. We recommend a quality improvement project or a critical outcomes-based triage system to assess ACS patients' care needs in the ED.

Causal Association of Physician-in-Triage with Improved Pediatric Sepsis Care: A Single-Center, Emergency Department Experience

Approximately 75,000 children are hospitalized for sepsis yearly in the United States, with 5%-20% mortality estimates. Outcomes are closely related to the timeliness of sepsis recognition and antibiotic administration.

Methods

A multidisciplinary sepsis task force formed in the Spring of 2020 aimed to assess and improve pediatric sepsis care in the pediatric emergency department (ED). The electronic medical record identified pediatric sepsis patients from September 2015 to July 2021. Data for time to sepsis recognition and antibiotic delivery were analyzed using statistical process control charts (X̄-S charts). We identified special cause variation, and Bradford-Hill Criteria guided multidisciplinary discussions to identify the most probable cause.

Results

In the fall of 2018, the average time from ED arrival to blood culture orders decreased by 1.1 hours, and the time from arrival to antibiotic administration decreased by 1.5 hours. After qualitative review, the task force hypothesized that initiation of attending-level pediatric physician-in-triage (P-PIT) as a part of ED triage was temporally associated with the observed improved sepsis care. P-PIT reduced the average time to the first provider exam by 14 minutes and introduced a process for physician evaluation before ED room assignment.

Conclusions

Timely assessment by an attending-level physician improves time to sepsis recognition and antibiotic delivery in children who present to the ED with sepsis. Implementing a P-PIT program with early attending-level physician evaluation is a potential strategy for other institutions.

Weighing up the pros and cons of dysphagia triage in South Africa

BACKGROUND

 Early identification of dysphagia followed by intervention reduces, length of hospitalisation, degree of morbidity, hospital costs and risk of aspiration pneumonia. The emergency department offers an opportune space for triage. Triaging offers risk-based evaluation and early identification of dysphagia risk. A dysphagia triage protocol is not available in South Africa (SA). The current study aimed to address this gap.

OBJECTIVES

 To establish the reliability and validity of a researcher-developed dysphagia triage checklist.

METHOD

 A quantitative design was used. Sixteen doctors were recruited from a medical emergency unit at a public sector hospital in SA using non-probability sampling. Non-parametric statistics and correlation coefficients were used to determine the reliability, sensitivity and specificity of the checklist.

RESULTS

 Poor reliability, high sensitivity and poor specificity of the developed dysphagia triage checklist was found. Importantly, the checklist was adequate in identifying patients as not being at risk for dysphagia. Completion time for dysphagia triage was 3 minutes.

CONCLUSION

 The checklist was highly sensitive but not reliable or valid for use in identifying patients at risk for dysphagia.Contribution: The study provides a platform for further research and modification of the newly developed triage checklist, which is not recommended for use in its current form. The merits of dysphagia triage cannot be ignored. Once a valid and reliable tool is confirmed, the feasibility of implementation of dysphagia triage must be considered. Evidence to confirm that dysphagia triage can be conducted, when considering the contextual, economic, technical and logistic aspects of the context, is necessary.

Creating a Rapid Assessment Zone with Limited Emergency Department Capacity Decreases Patients Leaving Without Being Seen: A Quality Improvement Initiative

INTRODUCTION

Patients leaving the emergency department before treatment (left without being seen) result in increased risks to patients and loss of revenue to the hospital system. Rapid assessment zones, where patients can be quickly evaluated and treated, have the potential to improve ED throughput and decrease the rates of patients leaving without being seen. We sought to evaluate the impact of a rapid assessment zone on the rate of patients leaving without being seen.

METHODS

A pre- and post-quality improvement process was performed to examine the impact of implementing a rapid assessment zone process at an urban community hospital emergency department. Through a structured, multidisciplinary approach using the Plan, Do, Check, Act Deming Cycle of process improvement, the triage area was redesigned to include 8 rapid assessment rooms and shifted additional ED staff, including nurses and providers, into this space. Rates of patients who left without being seen, median arrival to provider times, and discharge length of stay between the pre- and postintervention periods were compared using parametric and nonparametric tests when appropriate.

RESULTS

Implementation of the rapid assessment zone occurred February 1, 2021, with 42,115 ED visits eligible for analysis; 20,731 visits before implementation and 21,384 visits after implementation. All metrics improved from the 6 months before intervention to the 6 month after intervention: rate of patients who left without being seen (5.64% vs 2.55%; c² = 258.13; P < .01), median arrival to provider time in minutes (28 vs 11; P < .01), and median discharge length of stay in minutes (205 vs 163; P < .01).

DISCUSSION

Through collaboration and an interdisciplinary team approach, leaders and staff developed and implemented a rapid assessment zone that reduced multiple throughput metrics.

Strategies to improve the quality of nurse triage in emergency departments: A realist review protocol

AIM

The purpose of this realist review was to assess what works, for whom and in what context, regarding strategies that influence nurses' behaviour to improve triage quality in emergency departments (ED).

DESIGN

Realist review protocol.

METHODS

This protocol follows the PRISMA-P statement and will include any type of study on strategies to improve the triage process in the ED (using recognized and validated triage scales). The included studies were examined for scientific quality using the Mixed Methods Appraisal Tool. The framework for this realist review is based on the Behaviour Change Wheel (BCW) and the context-mechanism-outcome (CMO) models.

DISCUSSION

Nurses and ED decision makers will be informed on the evidence regarding strategies to improve the quality of triage and the factors required to maximize their effectiveness. Research gaps may also be identified to guide future research projects on the adoption of best practices in ED nursing triage.

The Undertriage of Older Adults in the Emergency Department: A Review of Interventions

The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse and the emergency nurse and to assist with the translation of research into practice. A topic and a research study are selected for each column. A patient scenario is presented as a vehicle, in which to review and critique, the findings of the selected research study. In this column, we review the conclusions of A. Malinovska, L. Pitasch, N. Geigy, C. H. Nickel, and R. Bingisser (2019) from their article, titled "Modification of the Emergency Severity Index Improves Mortality Prediction in Older Patients."

Implementation of a Multifactorial Strategy Including Direct Bedding Is Associated With a Rapid and Sustained Reduction in Left Without Being Seen

Objective

Improve left without being seen (LWBS) in our high volume, tertiary care trauma center. Prior to intervention, our LWBS rate was 4.4%. Including a direct bedding strategy, we successfully reduced our LWBS to <1%.

Design and method

We utilized a retrospective before and after model. We hired a clinical documentation specialist and tracked several metrics. These included daily census, admission rates, and door to provider, door to room, average boarding, and door to disposition times. Data were collected and disseminated daily. Reports were shared at organization quality meetings. Simultaneously, we implemented the direct bedding initiative in conjunction with quick registration. To accommodate higher numbers of patients and expediate movement to care spaces, all patient spaces were clearly designated and labeled.

Results

Direct bedding began in September 2015 and our LWBS was 4.4%. One-year post-intervention, our LWBS was <2%. Within four years, it was <0.5%. The LWBS rate for each year, 2016 to 2019, was significantly lower than the control period (p < 0.01) (2015 up to September). Improvement was also seen in door-to-provider time and with patient experience scores.

Conclusion

Our multifactorial approach was associated with a profound and sustained reduction in LWBS over a short time period.

A Front-end Redesign With Implementation of a Novel "Intake" System to Improve Patient Flow in a Pediatric Emergency Department

Introduction

Children's Hospital Colorado is an academic, tertiary-care Level 1 Trauma Center with an emergency department (ED) that treats >70,000 patients/year. Patient volumes continue to increase, leading to worsening wait times and left-without-being-seen (LWBS) rates. In 2015, the ED's median door-to-provider time was 49 minutes [interquartile range (IQR) = 26-90], with a 3.2% LWBS rate. ED leadership, staff, and providers aimed to improve patient flow with specific goals to (1) decrease door-to-provider times to a median of <30 minutes and (2) decrease annual LWBS rate to <1%.

Methods

An inter-professional team utilized quality improvement and Lean methodology to study, redesign, and implement significant changes to ED front-end processes. Key process elements included (1) new Flow Nurse/EMT roles, (2) elimination of traditional registration and triage processes, (3) immediate "quick registration" and nurse assessment upon walk-in, (4) direct-bedding of patients, and (5) a novel "Intake" system staffed by a pediatric emergency medicine physician.

Results

In the 12 months following full implementation of the new front-end system, the median door-to-provider time decreased 49% to 25 minutes (IQR = 13-50), and the LWBS rate decreased from 3.2% to 1.4% (a 56% relative decrease). Additionally, the percentage of patients seen within 30 minutes of arrival increased, overall ED length-of-stay decreased, patient satisfaction improved, and no worsening of the unexpected 72-hour return rate occurred.

Conclusions

Using quality improvement and Lean methodology, an inter-professional team decreased door-to-provider times and LWBS rates in a large pediatric ED by redesigning its front-end processes and implementing a novel pediatric emergency medicine-led Intake system.

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.

The Impact of a Concierge Medicine Model on Door to Doctor Time and Patient Flow in an Urban Emergency Department

Introduction

Emergency Department (ED) crowding negatively impacts patient outcomes, patient satisfaction, and patient safety. One solution involves introducing a Concierge Physician (CP) whose sole purpose is to provide a brief initial assessment (BIA) and aid patient navigation through the ED. The goal of this study was to quantify the impact of a CP on patient flow dynamics in an urban ED setting.

Methods

We performed a retrospective observational cohort study in an urban academic ED over a 6-month period. Initially, the CP was present in the treatment area during weekdays; during the last half of the observation period, an additional CP was added to the waiting room on weekends. We identified four major milestones in the ED visit with regards to patient throughput. Adult patients presenting to the ED with a triage level of Urgent (ESI 3) were analyzed for this study. Data were stratified based on the patient's ultimate disposition (admitted or discharged) and presented as means with predictive analysis.

Results

Between August 2016 and January 2017, the ED evaluated 42,397 adult patients. Of those, 26,976 (64%) were triage level Urgent (3). Of the level 3 patients, 10,279 (38%) received a BIA from a CP. Patients evaluated by a CP were seen approximately 30 mins faster (40% reduction in Door to Doctor time), but stayed 30 mins longer in the ED on average, because the medical decision-making process took >1 hr longer when the patient was initially evaluated by a CP.

Conclusion

Adapting a concierge medicine model to rapidly evaluate patients resulted in a dramatically reduced Door to Doctor time, but an increase in overall time spent in the ED. This discrepancy was a direct result of the delay in physician disposition.