The Effectiveness of a Provider in Triage in the Emergency Department

A comparison between the impacts of lecturing and flipped classrooms in virtual learning on triage nurses' knowledge and professional capability: an experimental study

BACKGROUND

The quality of triage in emergency department depends on regular evaluation of triage nurses' professional capabilities and development of programs to improve them. Flipped classrooms are a new approach to learning which can be employed to improve professional capabilities. The present study aims to compare the impact of lecturing to flipped classrooms in virtual learning on the knowledge and professional capabilities of triage nurses in the emergency departments of the state hospitals of Yazd province in south-western Iran in 2022.

METHODS

The present study is an experimental work of research. Seventy-four triage nurses participated in the study. Seventy-four triage nurses were randomly allocated to the two groups, including flipped classrooms (group B) and lecturing (group A). The data collection instruments were an emergency department triage nurses' professional capability questionnaire and a triage knowledge questionnaire. The collected data were analyzed in SPSS v.22 using independent t-test, chi-squared test, and repeated measures analysis of variance. Level of significance was set at p ≥ 0.05.

RESULTS

The participants' mean age was 33.1 ± 4.3 years. As measured one month after the education, the triage knowledge mean score of the nurses who were educated using the flipped classroom method (9.29 ± 1.73) was higher than that of the nurses who were educated via lecturing (8.45 ± 1.788), and the difference was statistically significant (p = 0.001). Also, measured one month after the education, the professional capability mean score of the nurses who were educated using the flipped classroom method (140.27 ± 11.744) was higher than that of the nurses who were educated via lecturing (132.84 ± 10.817), and the difference was statistically significant (p = 0.006).

CONCLUSION

There was a significant difference between the pretest and posttest knowledge and professional capability mean scores of both groups immediately after the education. However, measured one month after the education, the mean and standard deviation of the knowledge and professional capability scores of the triage nurses who had been educated via flipped classrooms were higher than those of the nurses in the lecturing group. Thus, virtual learning using flipped classrooms is more effective than lecturing in improving triage nurses' knowledge and professional capability in the long run.

Investigating the professional capability of triage nurses in the emergency department and its determinants: a multicenter cross-sectional study in Iran

BACKGROUND

Planning to improve the professional capabilities of triage nurses requires determining the level of professional capabilities and its determinants. In this regard, the present study was conducted to determine the professional capability of triage nurses and its determinants for the first time in Iran.

METHODS

A descriptive cross-sectional multicenter study was conducted in 2022. The research population included all nurses working in triage units of emergency departments of seven selected hospitals in Fars Province, south of Iran. The samples were selected using convenience sampling. The data collection tools were the "Triage nurses' professional capability questionnaire in the emergency department" and a questionnaire to investigate determinants of triage nurses' professional capability. Descriptive and analytical (Pearson's correlation test and multiple linear regression analysis) were used for data analysis in the SPSS software version 27. P values ≤ 0.05 were considered significant.

RESULTS

Out of 580 participants, 342 (59%) were female. The professional capability of triage nurses was at a moderate level with a mean score of 124.11 ± 14.72. The mean score of clinical competence, psychological empowerment, and professional commitment was 71.56 ± 9.67, 19.86 ± 3.95, and 32.69 ± 3.54, respectively. The results of multiple linear regression analysis showed that 5 factors, including participation in educational courses (p < 0.001), having clinical experience and specialized knowledge in emergency department (p < 0.001), error registry and assessment system (p < 0.001), managers' support (p < 0.001), and recruiting experienced staff (p = 0.018) affected the nurses' professional capability.

CONCLUSION

In the present study, the triage nurses had moderate levels of professional capability. It is necessary that nursing managers develop effective plans to improve the professional capability of triage nurses in emergency departments to enhance the quality and effectiveness of emergency services.

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.

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.

Implementation of a Provider in Triage and Its Effect on Left without Being Seen Rate at a Community Trauma Center

Introduction

Emergency department (ED) overcrowding is a nationally recognized problem and multiple strategies have been proposed and implemented with varying levels of success. It has caused patients to present to the ED but leave without being seen (LWBS). These patients suffer delayed diagnosis, delayed treatment, and ultimately increased morbidity and mortality. In efforts to decrease the number of patients who leave without being seen, one proposed solution is to place a provider in triage to evaluate these patients at the initial point of contact.

Methods

A retrospective chart review was conducted on patient’s presenting to the Emergency Department from October through January for the years 2013 through 2017. A list of all patient dispositions for each study month was analyzed and compared for the 4 consecutive years with the implementation of an Advanced Practice Provider (APP) in triage.

Results

A total of 2162 patients dispositioned as LWBS during the entire study period of October 2013 through January 2017 were enrolled in the analysis. After implementation of a provider in triage, there was a 39% overall decrease (95% CI 0.005) in patients who left the ED before completion of treatment. There was a 69% reduction (95% CI 0.005) in patients who left before seeing the provider in triage. After seeing the provider, we saw an 83% reduction (95% CI<0.001) in LWBS. Overall, our initial LWBS rate was found to be 5%, and after implementation of a provider in triage that rate decreased to 1%.

Discussion

The addition of a provider in triage decreased our LWBS rate from 5% to 1%. The addition of a provider in triage also helped identify sick patients in the waiting room and helped facilitate more rapid assessment of ED patients on arrival.

The role and contribution of nurses to patient flow management in acute hospitals: A systematic review of mixed methods studies

BACKGROUND

Increased overcrowding in the emergency department is a potential threat to the quality and safety of patient care. Innovative ways are needed to explore overcrowding, the variables affecting patient flow and interventions necessary for future flow improvement.

AIMS AND OBJECTIVES

The aim of this review is to explore nurses' role(s) and their contribution to maintaining patient flow in acute hospitals through emergency departments.

METHODOLOGY

A systematic review of mixed studies (qualitative, quantitative and mixed-method) using narrative synthesis was undertaken. Five major databases-PubMed, CINHAL, BNI, ASSIA and SCOPUS-were searched to identify appropriate primary and secondary studies. Selected studies were critically appraised with a modified CASP tool. Data extraction and analysis was undertaken using narrative synthesis.

RESULTS

In total, 34 articles (31 primary studies and three systematic reviews) met the inclusion criteria. This systematic review is informed by studies from several countries, including the UK, US, Australia, Canada, and the Netherlands. The qualitative arm of this review explored both the role and function of nurses, as well as their experiences and perspectives of the patient flow process, while the quantitative arm investigated nurses' contribution to patient flow in terms of length of stay (LOS), triage time, and other associated performance data.

FINDINGS

Nurses' contribution to patient flow spanned their operational, strategic, and expanded roles. Strategic and expanded nursing roles offered the possibility of reducing LOS, triage time, and ED crowding in addition to improving the experience of patients and staff. Nurses in operational roles deployed experiential knowledge pertaining to several invisible aspects of patient flow challenges thereby facilitating decision-making for strategic flow improvement. The experiential knowledge and skills of these nursing roles are central to the success of flow-related interventions. However, the effects of emotional labour (e.g. conflicts, frustrations) of patient flow processes on nurses are significant and may have unaccounted for transaction costs and consequences that need acknowledging in order to be addressed by managers and policy makers.

CONCLUSIONS AND RECOMMENDATIONS

Policy-makers and senior managers need to capitalise on nurses' experiential knowledge and skills to enhance the strategic design and development of flow management in acute hospitals. Recommendations from this review have potential to deploy those skills and knowledge in flow improvement.

Factors Affecting Emergency Department Crowding

Emergency department crowding is a multifactorial issue with causes intrinsic to the emergency department and to the health care system. Understanding that the causes of emergency department crowding span this continuum allows for a more accurate analysis of its effects and a more global consideration of potential solutions. Within the emergency department, boarding of inpatients is the most appreciable effect of hospital-wide crowding, and leads to further emergency department crowding. We explore the concept of emergency department crowding, and its causes, effects, and potential strategies to overcome this problem.

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.

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.

Cost and Visit Duration of Same-Day Access at an Academic Ophthalmology Department vs Emergency Department

Importance

Convenient outpatient access for ophthalmology patients seeking urgent care could offer savings compared with an emergency department (ED) visit.

Objective

To evaluate the costs and visit durations of same-day access (SDA) in an ophthalmology department at an academic medical center vs ED care.

Design, Setting, and Participants

This single-center study was a retrospective quality improvement analysis of an institutional electronic medical record system at the Wilmer Eye Institute clinics and the Johns Hopkins Hospital ED. On June 1, 2015, the Wilmer Eye Institute and Johns Hopkins Hospital initiated an official policy of providing SDA to patients calling for appointments (ie, the same-day project). All ophthalmology clinic locations created same-day appointment slots for at least 1 practitioner. In recognition of seasonal variations in patient visit volumes, the 10 months before implementation (August 1, 2014, to May 31, 2015) were compared with complementary periods in 2015 to 2016 and 2016 to 2017.

Main Outcomes and Measures

The study tabulated encounters, charges, and visit length for outpatients seen on the same day or by previously scheduled appointments. For the ED patients, volume, diagnoses, charges, and length of stay data were collected. The numbers of SDA patients who indicated urgency were tabulated.

Results

The number of SDA patients increased from 22 781 to 26 579 for the first year after SDA implementation. The mean charge was $258 (95% CI, $250-$266; median, $184; interquartile range [IQR], $175-$320), and the mean clinic transit time was 1.55 hours (95% CI, 1.54-1.57 hours; median, 1.28 hours). For patients seeking eye care in the ED, the mean professional fee was $401 (95% CI, $390-$411; median, $360; IQR, $255-$500), the mean (SD) total hospital charge was $1040 ($999) (95% CI, $729-$1079; median, $1002; IQR, $334-$1429), and the mean length of stay was 7.30 hours (95% CI, 7.01-7.57 hours; median, 7.20 hours). The top 4 ophthalmic diagnoses for ED patients were conjunctivitis, cornea abrasion, iritis, and visual loss, which were unchanged after SDA implementation. In calendar year 2017, a total of 4062 SDA patients reported urgency; their estimated savings in charges compared with an ED visit were $580 866 in professional fees and $3 176 484 in hospital charges.

Conclusions and Relevance

Same-day access appears to be less expensive and to require less time in the health care system than a visit to the ED for an ophthalmic diagnosis. Substantial savings in time and money might be achieved if urgent eye care is delivered in the clinic rather than the ED.

Improving emergency department transfer for patients arriving by ambulance: A retrospective observational study

Objective

Extended delays in the transfer of patients from ambulance to ED can compromise patient flow. The present study aimed to describe the relationship between the use of an Emergency Department Ambulance Off‐Load Nurse (EDAOLN) role, ED processes of care and cost effectiveness.

Methods

This was a retrospective observational study over three periods of before (T1), during (T2) and after (T3) the introduction of the EDAOLN role in 2012. Ambulance, ED and cost data were linked and used for analysis. Processes of care measures analysed included: time to be seen by a doctor from ED arrival (primary outcome), ambulance‐ED offload compliance, proportion of patients seen within recommended triage timeframe, ED length of stay (LoS), proportion of patients transferred, admitted or discharged from the ED within 4 h and cost effectiveness.

Results

A total of 6045 people made 7010 presentations to the ED by ambulance over the study period. Several measures improved significantly between T1 and T2 including offload compliance (T1: 58%; T2: 63%), time to be seen (T1: 31 min; T2: 28 min), ED LoS (T1: 335 min; T2: 306 min), ED LoS <4 h (T1: 31%; T2: 33%). Some measures carried over into T3, albeit to a lesser extent. Post‐hoc analyses showed that outcomes improved most for less urgent patients. The annualised net cost of the EDAOLN (if funded from additional resources) of $130 721 could result in an annualised reduction of approximately 3912 h in waiting time to be seen by a doctor.

Conclusion

With the EDAOLN role in place, slight outcome improvements in several key ambulance and ED efficiency criteria were noted. During times of ED crowding, the EDAOLN role may be one cost‐effective strategy to consider.

Challenges and Barriers Affecting the Quality of Triage in Emergency Departments: A Qualitative Study

Background

Correct and fast triage is the key to successful performance in emergency departments. Various factors can affect the quality of triage; therefore, the present study was conducted to identify and explore the existing challenges in triage units in emergency departments.

Materials and Methods

The present study was a qualitative exploratory work conducted via the content analysis approach. Data were collected using in-depth, semi-structured interviews, and focus group interviews. Accordingly, 22 in-depth, semi-structured interviews were conducted in with 18 triage nurses and four emergency medicine specialists on a face-to-face basis.

Results

The challenges related to triage nurses fall into two subcategories; lack of clinical competency and psychological capabilities. The challenges related to emergency management consist of challenges in human resources management, structural, and performance.

Conclusion

The challenges existing in triage units are influenced by factors related to triage nurses and emergency management. Emergency administrators can improve the effectiveness and quality of triaging patients by empowering triage nurses and removing structural problems in triage units.

Expanding knowledge and roles for authority and practice boundaries of Emergency Department nurses: a grounded theory study

Purpose: While emergency department nurses in Indonesia are critical to quality care, the role lacks recognition and standard practices and regulation of scope of practice are absent. This research explored the role of nurses in Indonesian EDs.

Method: The conceptual lens applied in the research was grounded theory. The main data source was 51 semi- structured interviews with 43 ED nurses, three directors of nursing, three nurse leaders and two nurse educators. Data were also generated through observations and memos.

Results: Two key categories were constructed; shifting work boundaries and lack of authority. Shifting work boundaries was symbolic of a lack of professional authority and legitimized knowledge. Lack of authority reflected the dimension of professional autonomy through the nexus of power and knowledge. The interrelationship of these two concepts constructed a core category, securing legitimate power, which underpinned the positioning of nursing in Indonesia.

Conclusions: The interconnection between political gains, tertiary knowledge, professional regulation and implementation of gender-sensitive policies was critical to the development of the ED role, the positioning of nursing within the health care system and improvement in quality of care.

Emergency Medicine Resident Efficiency and Emergency Department Crowding

OBJECTIVES

Provider efficiency has been reported in the literature but there is a lack of efficiency analysis among emergency medicine (EM) residents. We aim to compare efficiency of EM residents of different training levels and determine if EM resident efficiency is affected by emergency department (ED) crowding.

METHODS

We conducted a single-center retrospective observation study from July 1, 2014, to June 30, 2017. The number of new patients per resident per hour and provider-to-disposition (PTD) time of each patient were used as resident efficiency markers. A crowding score was assigned to each patient upon the patient's arrival to the ED. We compared efficiency among EM residents of different training levels under different ED crowding statuses. Dynamic efficiency changes were compared monthly through the entire academic year (July to next June).

RESULTS

The study enrolled a total of 150,920 patients. A mean of 1.9 patients/hour was seen by PGY-1 EM residents in comparison to 2.6 patients/hour by PGY-2 and -3 EM residents. Median PTD was 2.8 hours in PGY-1 EM residents versus 2.6 hours in PGY-2 and -3 EM residents. There were no significant differences in acuity across all patients seen by EM residents. When crowded conditions existed, residency efficiency increased, but such changes were minimized when the ED became overcrowded. A linear increase of resident efficiency was observed only in PGY-1 EM residents throughout the entire academic year.

CONCLUSION

Resident efficiency improved significantly only during their first year of EM training. This efficiency can be affected by ED crowding.

NHAMCS Validation of Emergency Severity Index as an Indicator of Emergency Department Resource Utilization

Introduction

Triage systems play a vital role in emergency department (ED) operations and can determine how well a given ED serves its local population. We sought to describe ED utilization patterns for different triage levels using the National Hospital Ambulatory Medical Care Survey (NHAMCS) database.

Methods

We conducted a multi-year secondary analysis of the NHAMCS database from 2009-2011. National visit estimates were made using standard methods in Analytics Software and Solutions (SAS, Cary, NC). We compared patients in the mid-urgency range in regard to ED lengths of stay, hospital admission rates, and numbers of tests and procedures in comparison to lower or higher acuity levels.

Results

We analyzed 100,962 emergency visits (representing 402,211,907 emergency visits nationwide). In 2011, patients classified as triage levels 1–3 had a higher number of diagnoses (5.5, 5.6 and 4.2, respectively) when compared to those classified as levels 4 and 5 (1.61 and 1.25). This group also underwent a higher number of procedures (1.0, 0.8 and 0.7, versus 0.4 and 0.4), had a higher ED length of stay (220, 280 and 237, vs. 157 and 135), and admission rates (32.2%, 32.3% and 15.5%, vs. 3.1% and 3.6%).

Conclusion

Patients classified as mid-level (3) triage urgency require more resources and have higher indicators of acuity as those in triage levels 4 and 5. These patients’ indicators are more similar to those classified as triage levels 1 and 2.

Effectiveness of Resident Physicians as Triage Liaison Providers in an Academic Emergency Department

Introduction

Emergency department (ED) crowding is associated with detrimental effects on ED quality of care. Triage liaison providers (TLP) have been used to mitigate the effects of crowding. Prior studies have evaluated attending physicians and advanced practice providers as TLPs, with limited data evaluating resident physicians as TLPs. This study compares operational performance outcomes between resident and attending physicians as TLPs.

Methods

This retrospective cohort study compared aggregate operational performance at an urban, academic ED during pre- and post-TLP periods. The primary outcome was defined as cost-effectiveness based upon return on investment (ROI). Secondary outcomes were defined as differences in median ED length of stay (LOS), median door-to-provider (DTP) time, proportion of left without being seen (LWBS), and proportion of “very good” overall patient satisfaction scores.

Results

Annual profit generated for physician-based collections through LWBS capture (after deducting respective salary costs) equated to a gain (ROI: 54%) for resident TLPs and a loss (ROI: −31%) for attending TLPs. Accounting for hospital-based collections made both profitable, with gains for resident TLPs (ROI: 317%) and for attending TLPs (ROI: 86%). Median DTP time for resident TLPs was significantly lower (p<0.0001) than attending or historical control. Proportion of “very good” patient satisfaction scores and LWBS was improved for both resident and attending TLPs over historical control. Overall median LOS was not significantly different.

Conclusion

Resident and attending TLPs improved DTP time, patient satisfaction, and LWBS rates. Both resident and attending TLPs are cost effective, with residents having a more favorable financial profile.

A Systematic Approach to Evaluation of Performance Deficiencies in ED Triage

CONTRIBUTION TO EMERGENCY NURSING PRACTICE

• Nurses are uniquely situated to critically evaluate quality and performance measures, identify opportunities for improvement, and recommend potential corrective inverventions within the emergency department. • Nurses can actively contribute to performance improvements that increase quality of care, improve patient outcomes and satisfaction, and reduce institutional liability and risk. • Establishment of a systematic process to identify deficiencies, evaluate problems, and develop solutions is vital to continuous quality improvement.

ABTRACTPROBLEM

Increasing ED crowding has resulted in greater demand and longer time-to-triage and time-to-provider wait times, making accurate triage more important than ever before to avoid poor patient outcomes and possible hospital liability. In one case, a 75-year-old patient presenting with chest pain became unconscious in the ED waiting area after initial registration but before triage. Although resuscitation was attempted, the patient did not survive. Continuous assessment and improvement are needed to streamline the triage process and improve accuracy and efficiency. Because nurses play a vital role in patient triage, they are uniquely positioned to evaluate and enhance the process.

METHODS

When staff at an 18-bed emergency department in a rural hospital suspected potential quality deficiencies related to extended wait times and patients leaving without being seen, a panel of nurses was formed to characterize the problem by conducting a chart review to develop potential solutions.

RESULTS

The chart review identified a correlation between wait times and patients leaving without being seen during hours of peak demand. Accordingly, the panel collaborated and proposed several interventions to alleviate these problems.

IMPLICATIONS FOR PRACTICE

Formation of a panel of skilled nurses to assess problems and recommend potential solutions may represent a useful approach for active nurse participation in quality improvement in the emergency department, thus having a meaningful impact on patient outcomes and hospital liability.

Impact of a Planned Workflow Change: Super Track Improves Quality and Service for Low-Acuity Patients at an Inner-City Hospital

ED volume and acuity were anticipated to increase at an inner-city hospital. A strategy to mitigate the impact was needed.

METHODS

A multidisciplinary team facilitated a workflow modification project implementing a Super Track to treat low-acuity patients. A literature review led to the creation of an evidence-based framework. Staff education regarding the change process and the results of an analysis in the strengths, weaknesses, opportunities, and threat format, along with simulation exercises and a pilot project, supported implementation of this strategy.

RESULTS

Simulation exercises demonstrated that the proposed workflow with a Super Track had the potential to reduce the length of stay among level 4 and 5 patients coming to the emergency department. Implementing a Super Track reduced the patient arrival-to-provider time for low-acuity patients, but length of stay was not affected. After implementation, the number of patients who left without being seen decreased by 40%, and patient satisfaction increased by 36%.

IMPLICATIONS FOR PRACTICE

A modified front-end workflow process produced a statistically significant, sustainable improvement in patient flow of low-acuity patients in our emergency department. Use of an evidence-based, multidisciplinary team approach supported the change process.

Validity and reliability of a novel Color-Risk Psychiatric Triage in a psychiatric emergency department

BACKGROUND

Classification of Psychiatric Emergency Presentations (PEP) is not sufficiently clear due to their inherent high inter-subjectivity and lack of validated triage instruments. In order to improve current classification of psychiatric emergency presentations (PEP) at Emergency Departments, we implemented and validated the Color-Risk Psychiatric Triage (CRPT), an instrument for classifying PEP risk by sorting one to five color/risk levels and one to thirty-two possible conditions arranged by risk.

METHODS

Users who visited the Emergency Department (ED) of a Mexican psychiatric hospital from Dec 1st, 2008 to Dec 1st, 2009 were included. One CRPT was assessed by an ED psychiatrist to each patient upon their arrival to ED. Some patients were randomly assessed simultaneously with an additional CRPT and a Crisis and Triage Rating Scale (CTRS) to test validity and reliability of the CRPT.

RESULTS

A total of 7,631 CRPT assessments were included. The majority of PEP were non-urgent (74.28 %). For the validation phase n = 158 patients were included. CRPT score showed higher concurrent validity than CRPT color/risk. CRPT level/risk and score showed highest concurrent validity within dangerousness domain of CTRS (r = 0.703, p < 0.0001). CRPT and CTRS scores showed similar predictive validity (p < 0.0001). High intraclass correlation coefficient (0.982) and Cohen's Kappa (0.89) were observed for CRPT score (r = 0.982, p < 0.0001).

CONCLUSIONS

CRPT appeared to be a useful instrument for PEP classification due to its concurrent validity, predictive validity and reliability. CRPT score showed higher correlations than the CRPT color/risk. The five levels of risk provided by the CRPT appear to represent a simple and specific method for classifying PEP. This approach considers actual or potential risk, rather than severity, as the main factor for sorting PEP, which improves upon the current approach to emergency classification that is mainly based on the criterion of severity. Regardless of the triage procedure, emergency assessments should no longer classify PEP as "not real emergencies."

How the context of ambulance care influences learning to become a specialist ambulance nurse a Swedish perspective

OBJECTIVES

Ambulance emergency care is multifaceted with extraordinary challenges to implement accurate assessment and care. A clinical learning environment providing opportunities for mastering these essential skills is a key component in ensuring that prehospital emergency nurse (PEN) students acquire the necessary clinical competence.

AIM

The aim is to understand how PEN students experience their clinically based training, focusing on their learning process.

METHOD

We applied content analysis with its qualitative method to our material that consisted of three reflections each by 28 PEN students over their learning process during their 8 weeks of clinical ambulance practice. The research was carried out at the Center for Prehospital Care, University of Borås, Sweden.

RESULTS

The broad spectrum of ambulance assignments seems to awaken great uncertainty and excessive respect in the students. Student vulnerability appears to decrease when the clinical supervisor behaves calmly, knowledgeably, confidently and reflectively. Early traumatic incidents on the other hand may increase the students' anxiety. Each student is offered a unique opportunity to learn how to approach patients and relatives in their own environments, and likewise an opportunity to gather information for assessment. Infrequency of missions seems to make PEN students less active in their student role, thereby preventing them from availing themselves of potential learning situations. Fatigue and hunger due to lack of breaks or long periods of transportation also inhibit learning mode.

CONCLUSION

Our findings suggest the need for appraisal of the significance of the clinical supervisor, the ambulance environment, and student vulnerability. The broad spectrum of conditions in combination with infrequent assignments make simulation necessary. However, the unique possibilities provided for meeting patients and relatives in their own environments offer the PEN student excellent opportunities for learning how to make assessments.

Emergency Department Expansion Versus Patient Flow Improvement: Impact on Patient Experience of Care

BACKGROUND

Most strategies used to help improve the patient experience of care and ease emergency department (ED) crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both.

OBJECTIVES

To compare the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) on the patient experience of care in a medium-size safety net ED.

METHODS

This paper describes a study of a single ED wherein the department first undertook a physical expansion (2006 Q2 to 2007 Q2) followed by a reorganization of patient flow and establishment of an RAU (2009 Q2) by the use of an interrupted time series analysis.

RESULTS

In the time period after ED expansion, significant negative trends were observed: decreasing Press Ganey percentiles (-4.1 percentile per quarter), increasing door-to-provider time (+4.9 minutes per quarter), increasing duration of stay (+13.2 minutes per quarter), and increasing percent of patients leaving without being seen (+0.11 per quarter). After the RAU was established, significant immediate impacts were observed for door-to-provider time (-25.8 minutes) and total duration of stay (-66.8 minutes). The trends for these indicators further suggested the improvements continued to be significant over time. Furthermore, the negative trends for the Press Ganey outcomes observed after ED expansion were significantly reversed and in the positive direction after the RAU.

CONCLUSIONS

Our results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion.

Impact of a physician-in-triage process on resident education

INTRODUCTION

Emergency department (ED) crowding negatively impacts patient care quality and efficiency. To reduce crowding many EDs use a physician-in-triage (PIT) process. However, few studies have evaluated the effect of a PIT processes on resident education. Our objective was to determine the impact of a PIT process implementation on resident education within the ED of an academic medical center.

METHODS

We performed a prospective cross-sectional study for a 10-week period from March to June 2011, during operationally historic trended peak patient volume and arrival periods. Emergency medicine residents (three-year program) and faculty, blinded to the research objectives, were asked to evaluate the educational quality of each shift using a 5-point Likert scale. Residents and faculty also completed a questionnaire at the end of the study period assessing the perceived impact of the PIT process on resident education, patient care, satisfaction, and throughput. We compared resident and attending data using Mann-Whitney U tests.

RESULTS

During the study period, 54 residents and attendings worked clinically during the PIT process with 78% completing questionnaires related to the study. Attendings and residents indicated "no impact" of the PIT process on resident education [median Likert score of 3.0, inter-quartile range (IQR): 2-4]. There was no difference in attending and resident perceptions (p-value =0.18). Both groups perceived patient satisfaction to be "positively impacted" [4.0, IQR:2-4 for attendings vs 4.0, IQR:1-5 for residents, p-value =0.75]. Residents perceived more improvement in patient throughput to than attendings [3.5, IQR:3-4 for attendings vs 4.0, IQR:3-5 for residents, p-value =0.006]. Perceived impact on differential diagnosis generation was negative in both groups [2.0, IQR:1-3 vs 2.5, IQR:1-5, p-value = 0.42]. The impact of PIT on selection of diagnostic studies and medical decision making was negative for attendings and neutral for residents: [(2.0, IQR:1-3 vs 3.0, IQR:1-4, p-value =0.10) and (2.0, IQR:1-4 vs 3.0, IQR:1-5, p-value =0.14 respectively].

CONCLUSION

Implementation of a PIT process at an academic medical center was not associated with a negative (or positive) perceived impact on resident education. However, attendings and residents felt that differential diagnosis development was negatively impacted. Attendings also felt diagnostic test selection and medical decision-making learning were negatively impacted by the PIT process.

Provider in triage: is this a place for nurse practitioners?

The role of nurse practitioners (NPs) in emergency care continues to evolve. A new and exciting role is the provider-in-triage (PIT) role. This innovative role has been implemented in many emergency departments (EDs) across the country. It was developed primarily as a front-end strategy to improve throughput of patients receiving emergency care. The PIT process uses a provider, physician, NP, or physician assistant in the triage area. Patient satisfaction, quality measures, and financial improvements have been attributed to using a PIT. The emergency NP is an optimal choice for this role. Advanced emergency nursing knowledge, skills, and decision making confer the NP a cost-effective provider to improve throughput in the ED while providing quality emergency care.

An ED scribe program is able to improve throughput time and patient satisfaction

INTRODUCTION

At our institution, we previously described the detrimental effect of computerized physician order entry (CPOE) on throughput time and patient satisfaction (Ann of Emer Med, Vol 56, P S83-S84). To address these quality metrics, we conducted a pilot program using scribes in the emergency department (ED).

METHODS

We conducted a before-and-after study of ED throughput at our 320-bed suburban community hospital with a census of 70000 annual visits. Our primary outcome measure was the effect of scribes on ED throughput as measured by the effect on (1) door-to-room time; (2) room-to-doc time; (3) door-to-doc time; (4) doc-to-dispo time; and (5) length of stay for discharged/admitted patients, between pre-CPOE and post-CPOE cohorts. Our secondary outcome measure was patient satisfaction as provided by Press Ganey surveys. Data were analyzed using descriptive statistics, and means were compared using a standard t test.

RESULTS

Patient data from a total of 11729 patients in the before cohort were compared with data from 12609 patients in the after cohort. Despite a 7.5 % increase in volume between the post-CPOE and post-scribe cohorts, all throughput metrics improved in the post-scribe cohort. This process improved the overall door-to-doc time to 61 minutes in the after cohort from 74 minutes in the before cohort. Furthermore, patient and physician satisfaction was improved from the 58th and 62nd percentile to 75th and 92nd percentile, respectively.

Children's Mental Health Visits to the Emergency Department: Factors Affecting Wait Times and Length of Stay

Objective. This study explores the association of patient and emergency department (ED) mental health visit characteristics with wait time and length of stay (LOS). Methods. We examined data from 580 ED mental health visits made to two urban EDs by children aged ≤18 years from April 1, 2004, to March 31, 2006. Logistic regressions identified characteristics associated with wait time and LOS using hazard ratios (HR) with 95% confidence intervals (CIs). Results. Sex (male: HR = 1.48, 95% CI = 1.20-1.84), ED type (pediatric ED: HR = 5.91, 95% CI = 4.16-8.39), and triage level (Canadian Triage and Acuity Scale (CTAS) 2: HR = 3.62, 95% CI = 2.24-5.85) were statistically significant predictors of wait time. ED type (pediatric ED: HR = 1.71, 95% CI = 1.18-2.46), triage level (CTAS 5: HR = 2.00, 95% CI = 1.15-3.48), number of consultations (HR = 0.46, 95% CI = 0.31-0.69), and number of laboratory investigations (HR = 0.75, 95% CI = 0.66-0.85) predicted LOS. Conclusions. Based on our results, quality improvement initiatives to reduce ED waits and LOS for pediatric mental health visits may consider monitoring triage processes and the availability, access, and/or time to receipt of specialty consultations.

Emergency department boarding times for patients admitted to intensive care unit: Patient and organizational influences

INTRODUCTION

Critically ill patients can be subject to prolonged stays in the emergency department following receipt of an order to admit to an intensive care unit. The purpose of this study was to explore patient and organizational influences on the duration of boarding times for intensive care bound patients.

METHODS

This exploratory descriptive study was situated in a Canadian hospital in northern Ontario. Through a six-month retrospective review of three data sources, information was collected pertaining to 16 patient and organizational variables detailing the emergency department boarding time of adults awaiting transfer to the intensive care unit. Data analysis involved descriptive and non-parametric methods.

RESULTS

The majority of the 122 critically ill patients boarded in the ED were male, 55 years of age or older, arriving by ground ambulance on a weekday, and had an admitting diagnosis of trauma. The median boarding time was 34 min, with a range of 0-1549 min. Patients designated as most acute, intubated, and undergoing multiple diagnostic procedures had statistically significantly shorter boarding times.

DISCUSSION

The study results provide a profile that may assist clinicians in understanding the complex and site-specific interplay of variables contributing to boarding of critically ill patients.