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Sjöstedt H, Kindblom JM, Celind J. A low proportion of undertriage validates the new West coast system for triage-Paediatric. Acta Paediatr 2024; 113:999-1005. [PMID: 38235600 DOI: 10.1111/apa.17107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 01/01/2024] [Accepted: 01/04/2024] [Indexed: 01/19/2024]
Abstract
AIM There is a lack of studies on paediatric triage systems. This study aimed to evaluate patient safety of the Gothenburg-developed paediatric triage system West Coast System for Triage-Paediatric (WEST-P). METHOD This study was performed at the paediatric emergency department in Gothenburg, Sweden, October 2020 to April 2021. Included patients were double-triaged with the WEST-P, and the established Rapid Emergency Triage and Treatment System-Paediatrics (RETTS-p). We compared the level of urgency between both systems to identify potentially undertriaged patients. Also, we assessed the patient safety according to clinical assessment at presentation, and pre-defined criteria. RESULTS This study included 2290 (23%) of triaged patients (44% girls, median age: 5.0 years) during the study period. A higher number of patients triaged to low urgency in WEST-P compared to RETTS-p (p < 0.0001) was observed, and 497 cases with low WEST-P and high RETTS-p urgencies identified. Of these, 29 had a clinical assessment indicating high urgency. After patient safety assessment, seven (0.4%) were determined undertriaged by the new triage system WEST-P. CONCLUSION Our findings demonstrate a low risk of undertriage in the new WEST-P. Thus, the WEST-P has a high degree of patient safety when used in a paediatric emergency department.
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Affiliation(s)
- Hannah Sjöstedt
- Department of Paediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jenny M Kindblom
- Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Drug Treatment, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Jimmy Celind
- Department of Paediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Prasad S, Cullen E, Jowett C. Examining the Effectiveness of Telephone Clinics: A Review of a Telephone Foot and Ankle Orthopaedic Clinic in a District General Hospital in the United Kingdom. Cureus 2023; 15:e49196. [PMID: 38024093 PMCID: PMC10663046 DOI: 10.7759/cureus.49196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION Since the outbreak of COVID-19, significant value has been placed on preventative methods for pathogen spread. One such method is the use of telemedicine via telephone clinics (TC). This article is designed to study TC in a District General Hospital in the United Kingdom. AIMS This clinical audit aims to evaluate the use of a TC in the United Kingdom and assess its effectiveness. It also aims to assess the use of a clinician-led triaging system to select patients who would receive subsequent telephone follow-ups (TFU). METHODOLOGY Two cycles were conducted. The first cycle was conducted in 2020 and the second cycle in 2022. In between the two cycles, a clinician-led triage system was implemented to reduce the number of patients being called back for a face-to-face (FTF) appointment. Data was collected regarding the outcomes of the appointments and compared between the two cycles. Chi-squared test statistical test was employed with a p-value < 0.05 deeming significance. RESULTS Overall, more discharges were made for 2022 outcomes compared to 2020 outcomes (30% vs 19%; p = 0.03) after employing the clinician-led triage. The number of patients listed for a TFU increased when comparing the 2020 versus 2022 datasets (21% vs 12%; p = 0.026), and the overall number of patients not attending appointments decreased when comparing the 2020 versus 2022 datasets (9% vs 17%; p = 0.033). CONCLUSION This article shows that for this particular clinic, an orthopaedic clinician-led triaging system allows for a greater number of patients to be discharged, lessened need for FTF consultations, and increased adherence to appointments by patients. However, much work is yet to be done concerning the long-term consequences and issues of rolling out nationwide telemedicine.
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Affiliation(s)
- Surya Prasad
- Orthopaedics, The York Hospital, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, GBR
| | - Eleni Cullen
- Orthopaedics, The York Hospital, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, GBR
| | - Charlie Jowett
- Orthopaedics, The York Hospital, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, GBR
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3
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Milton J, M Gillespie B, Åberg D, Erichsen Andersson A, Oxelmark L. Interprofessional teamwork before and after organizational change in a tertiary emergency department: An observational study. J Interprof Care 2023; 37:300-311. [PMID: 35703726 DOI: 10.1080/13561820.2022.2065250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In healthcare settings, suboptimal interprofessional teamwork and communication contribute to unsafe care and avoidable harm. Interprofessional teamwork is essential in high-risk clinical areas such as the emergency department (ED). The aims of this study were to describe interprofessional teamwork in a hospital ED and to evaluate factors influencing interprofessional communication before and after implementation of a department-wide multifaceted intervention. Structured observations were undertaken during 2015/16 and 2019. Differences in interprofessional communication practices, teamwork, and sources of interruptions were compared before and after the intervention. The following domains were surveilled: (a) healthcare professionals (HCPs) communication initiatives, (b) HCPs' contribution to patient assessment, (c) interprofessional communication processes, and (d) team interruptions. The intervention included strategies to enable use of communication tools, changes to team structures, changes in work environment, ethical principles, and establishment of a code of professional conduct during interprofessional communication. Team interruptions significantly decreased post-intervention, and our findings suggest that organizational changes affect domains of teamwork. Statistically significant differences were observed in the initiated communication pre-intervention and contribution to patient assessment significantly increased post-intervention. Multifaceted organizational interventions can positively affect interprofessional team communication and work-flow in the ED, thus patient safety and quality of care can be improved.
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Affiliation(s)
- Jenny Milton
- Institute of Health and Care Sciences, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Brigid M Gillespie
- Gold Coast Health, Gold Coast University Hospital, Gold Coast, QLD, Australia.,School of Nursing and Midwifery & NHMRC Wiser Wounds Centre of Research Excellence, Griffith University, Brisbane, QLD, Australia
| | - David Åberg
- Department of Internal Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annette Erichsen Andersson
- Institute of Health and Care Sciences, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopedic Surgery, Region Västra Götaland, Sahlgrenska University Hospital Mölndal, Gothenburg, Sweden
| | - Lena Oxelmark
- Institute of Health and Care Sciences, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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Overcrowding in Emergency Department: Causes, Consequences, and Solutions—A Narrative Review. Healthcare (Basel) 2022; 10:healthcare10091625. [PMID: 36141237 PMCID: PMC9498666 DOI: 10.3390/healthcare10091625] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/23/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Overcrowding in Emergency Departments (EDs) is a phenomenon that is now widespread globally and causes a significant negative impact that goes on to affect the entire hospital. This contributes to a number of consequences that can affect both the number of resources available and the quality of care. Overcrowding is due to a number of factors that in most cases lead to an increase in the number of people within the ED, an increase in mortality and morbidity, and a decrease in the ability to provide critical services in a timely manner to patients suffering from medical emergencies. This phenomenon results in the Emergency Department reaching, and in some cases exceeding, its optimal capacity. In this review, the main causes and consequences involving this phenomenon were collected, including the effect caused by the SARS-CoV-2 virus in recent years. Finally, special attention was paid to the main operational strategies that have been developed over the years, strategies that can be applied both at the ED level (microlevel strategies) and at the hospital level (macrolevel strategies).
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Elalouf A, Wachtel G. Queueing Problems in Emergency Departments: A Review of Practical Approaches and Research Methodologies. OPERATIONS RESEARCH FORUM 2022. [PMCID: PMC8716576 DOI: 10.1007/s43069-021-00114-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Problems related to patient scheduling and queueing in emergency departments are gaining increasing attention in theory, in the fields of operations research and emergency and healthcare services, and in practice. This paper aims to provide an extensive review of studies addressing queueing-related problems explicitly related to emergency departments. We have reviewed 229 articles and books spanning seven decades and have sought to organize the information they contain in a manner that is accessible and useful to researchers seeking to gain knowledge on specific aspects of such problems. We begin by presenting a historical overview of applications of queueing theory to healthcare-related problems. We subsequently elaborate on managerial approaches used to enhance efficiency in emergency departments. These approaches include bed management, fast-track, dynamic resource allocation, grouping/prioritization of patients, and triage approaches. Finally, we discuss scientific methodologies used to analyze and optimize these approaches: algorithms, priority models, queueing models, simulation, and statistical approaches.
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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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Sainsbury R, Brennan R, Lockyer A. 'The incident triage area': a response to the COVID-19 pandemic in the Bristol Royal Infirmary. Emerg Med J 2021; 38:103-105. [PMID: 33257530 PMCID: PMC7705421 DOI: 10.1136/emermed-2020-209931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/05/2020] [Accepted: 10/28/2020] [Indexed: 11/17/2022]
Abstract
With the onset of the COVID-19 pandemic, hospitals nationwide have been presented with a number of potential challenges, including possible increased volume of patient attendances, acuity of illness and potential for patients to present with an infection that requires isolation. At the Bristol Royal Infirmary, an innercity teaching hospital that manages patients aged 16 and over, we present our response to these projected changes in ED attendances, with the initiation of the incident triage area (ITA). The ITA is a triage station situated outside the ED and staffed by a senior clinician, healthcare assistant and patient flow coordinator. It receives patients presenting as walk-in or via ambulance, and on their arrival aims to establish their risk of COVID-19 and their acuity of illness. This allows for triage of the patient to one of the four zones of the hospital, as well as providing clinical guidance on any initial interventions that patients may require. The benefits of the ITA are that it enables an early senior review of patients to establish their acuity of illness and initiate time-critical medical intervention as required. In addition, patients are immediately cohorted to zones within the hospital based on their infection risk, thereby reducing patient footfall throughout the hospital. Its aim is to reduce the spread of infection, by efficiently triaging and streaming patients who present to the hospital prior to them entering clinical areas, while maintaining patient safety and flow through the ED and initiating rapid management of acutely unwell patients.
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Affiliation(s)
| | - Rose Brennan
- Emergency Department, Bristol Royal Infirmary, Bristol, UK
| | - Andy Lockyer
- Emergency Department, Bristol Royal Infirmary, Bristol, UK
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Dreher-Hummel T, Nickel CH, Nicca D, Grossmann FF. The challenge of interprofessional collaboration in emergency department team triage - An interpretive description. J Adv Nurs 2020; 77:1368-1378. [PMID: 33245167 DOI: 10.1111/jan.14675] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/28/2020] [Accepted: 10/30/2020] [Indexed: 01/10/2023]
Abstract
AIMS To explore emergency nurses' and physicians' experience of collaboration and collective decision-making when triaging older Emergency Department patients within the interprofessional team triage system. DESIGN Qualitative. METHODS Semi-structured interviews were conducted with seven nurses and five physicians. Transcripts were analysed via Interpretive Description between September 2016-May 2017. RESULTS 'Negotiating collaboration' was developed as the main theme. Three subthemes influenced the negotiation process: Participants described divergent opinions on how an optimal triage system should work ('preferences for triage systems'); they had conflicting perceptions of each profession's role ('role perceptions'); and they expressed different coping strategies regarding 'perceived time pressure'. The compatibility of participants' views on these sub-themes determined whether the nurse and physician were able to successfully negotiate their collaboration. These themes became more evident when the team triaged older ED patients. CONCLUSION Improving interprofessional team triage requires working with the involved nurses' and physicians' values and beliefs. The strengths of both professions need to be considered and a flexible approach to collaboration established according to the patients' situations. IMPACT Emergency Department leaders need to consider nurses' and physicians' values and beliefs to promote interprofessional collaboration in team triage.
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Affiliation(s)
| | | | - Dunja Nicca
- Department of Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Florian F Grossmann
- Department of Medicine, Division of Nursing, Emergency Department, University Hospital Basel, Basel, Switzerland
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Schwarzfuchs D, Shashar S, Sagy I, Novack V, Zeldetz V. Does the physician in triage strategy improve door-to-balloon time for patients with STEMI? Emerg Med J 2020; 37:540-545. [DOI: 10.1136/emermed-2019-209241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 06/09/2020] [Accepted: 06/13/2020] [Indexed: 12/25/2022]
Abstract
BackgroundThe physician in triage (PIT) strategy was implemented in the emergency department (ED) of the Soroka University Medical Center (SUMC) to improve overcrowding and waiting time. Our objective in the current study was to assess the impact of the PIT strategy on door-to-balloon time for the treatment of acute ST-elevation myocardial infarction (STEMI).MethodsThe PIT programme began on January 2016, working weekdays between 8:00 and 23:00 hours. We included patients who visited the ED and were diagnosed with STEMI, from November 2014 to February 2018. The primary outcome was improvement in door-to-balloon (D2B) time <90 min between the preintervention and postintervention period. The analysis included a comparison between the two time periods using univariate tests, a time trend analysis illustrated by the locally weighted scatterplot smoothing curves and a regression analysis using generalised estimating equation models. To determine the impact of the PIT, as opposed to other changes in the department, we stratified the population arriving after January 2016 to patients arriving during PIT hours versus patients arriving on weekends and at nights (23:00–8:00 hours).ResultsIn all, 415 patients met all the inclusion criteria of which 237 (57.1%) visited on weekdays 8:00–23:00 hours. The per cent of patients with D2B <90 min was 13.9% higher for postintervention versus preintervention visits (p=0.006). D2B time was significantly shorter by 9 min for postintervention visits (p=0.001). In the postintervention period, patients arriving between 8:00 and 23:00 hours on weekdays were more likely to have D2B <90 min than those arriving nights and weekends; 90/146 (61.6%) vs 47.2% (51/108), respectively, p=0.02. ORs for D2B <90 min was 2.04 (95% CI 1.06 to 3.91) for weekday visits, and 1.90 (0.88 to 4.12) for weekend and night visits.ConclusionThe PIT model in SUMC is associated with D2B reduction for patients with STEMI. To achieve further reduction, both targeted interventions should be performed and PIT strategy should be applied for full time, including nights and weekends.
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Diagnosen einer Zentralen Notaufnahme als Qualitätsindikator. Notf Rett Med 2020. [DOI: 10.1007/s10049-019-0611-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Milton J, Chaboyer W, Åberg ND, Erichsen Andersson A, Oxelmark L. Safety attitudes and working climate after organizational change in a major emergency department in Sweden. Int Emerg Nurs 2020; 53:100830. [PMID: 32029416 DOI: 10.1016/j.ienj.2020.100830] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/11/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Medically complex patients present challenges to the health care system, particularly in the emergency department (ED) setting. Specifically, teamwork is thought to affect staff safety climate, which in turn impacts patient safety. AIM This study aimed to evaluate the effect of organizational changes to interprofessional team assessment processes on staff perception of teamwork and safety attitudes in the ED. METHODS This prospective observational study used cross-sectional design and measured ED staff perception of patient safety related domains at two time-points (before and after an organizational intervention), using the Safety Attitude Questionnaire. RESULTS Statistically significant changes were seen among the overall sample (n = 112 at time point one and n = 121 at time point two) for the safety climate, working conditions, and stress recognition domains. Nurses and doctors showed different baseline attitudes and different responses to the intervention between the two time points. CONCLUSION The results reflect improved positive attitudes overall though there were differences in responses between the nursing and medical professions. The findings highlight opportunities to improve attitudes among ED team members through defined organizational change and learning from one another. Organizational change can affect staff perceptions of the safety climate and interprofessional teamwork, which may improve the ED working environment.
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Affiliation(s)
- Jenny Milton
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Wendy Chaboyer
- Menzies Health Institute Queensland, School of Nursing, Griffith University, Gold Coast, Australia.
| | - N David Åberg
- Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Medicine, Gothenburg, Sweden.
| | - Annette Erichsen Andersson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopedic Surgery, Sahlgrenska University Hospital/Mölndal, Gothenburg, Sweden.
| | - Lena Oxelmark
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Medicine, Gothenburg, Sweden.
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12
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Emergency department overcrowding : Analysis and strategies to manage an international phenomenon. Wien Klin Wochenschr 2020; 133:229-233. [PMID: 31932966 DOI: 10.1007/s00508-019-01596-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/10/2019] [Indexed: 10/25/2022]
Abstract
Overcrowding in emergency departments is a common and worldwide phenomenon, which is widely reported even in the lay press. Strategies to address this incriminating situation for patients, nurses, physicians and hospital administrators are urgently needed. The current review presents an analysis of the overcrowding problem as well as strategies to answer overcrowding situations.
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Perniciaro JL, Schmidt AR, Pham PK, Liu DR. Defining "Swarming" as a New Model to Optimize Efficiency and Education in an Academic Emergency Department. AEM EDUCATION AND TRAINING 2020; 4:43-53. [PMID: 31989070 PMCID: PMC6965688 DOI: 10.1002/aet2.10388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/03/2019] [Accepted: 07/26/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Academic emergency medicine is a constant balance between efficiency and education. We developed a new model called swarming, where the bedside nurse, resident, and attending/fellow simultaneously evaluate the patient, including initial vital signs, bedside triage, focused history and physical examination, and discussion of the treatment plan, thus creating a shared mental model. OBJECTIVES To combine perceptions from trainee physicians, supervising physicians, nurses, and families with in vivo measurements of emergency department swarms to better conceptualize the swarming model. METHODS This mixed methods study was conducted using a convergent design. Qualitative data from focus groups with nurses, residents, and attendings/fellows were analyzed using directed content analysis. Swarming encounters were observed in real time; durations of key aspects and family satisfaction scores were analyzed using descriptive statistics. The qualitative and quantitative findings were integrated a posteriori. RESULTS From the focus group data, 54 unique codes were identified, which were grouped together into five larger themes. From 39 swarms, mean (±SD) time (minutes) spent in patient rooms: nurses = 6.8 (±3.0), residents = 10.4 (±4.1), and attendings/fellows = 9.4 (±4.3). Electronic documentation was included in 67% of swarms, and 39% included orders initiated at the bedside. Mean (±SD) family satisfaction was 4.8 (±0.7; Likert scale 1-5). CONCLUSIONS Swarming is currently implemented with significant variability but results in high provider and family satisfaction. There is also consensus among physicians that swarming improves trainee education in the emergency setting. The benefits and barriers to swarming are underscored by the unpredictable nature of the ED and the observed variability in implementation. Our findings provide a critical foundation for our efforts to refine, standardize, and appraise our swarming model.
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Affiliation(s)
- Jessica L. Perniciaro
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCA
- Department of PediatricsKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCA
| | - Anita R. Schmidt
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCA
| | - Phung K. Pham
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCA
| | - Deborah R. Liu
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCA
- Department of PediatricsKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCA
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Cicolo EA, Nishi FA, Peres HHC, Cruz DDALMD. Effectiveness of the Manchester Triage System on time to treatment in the emergency department: a systematic review. JBI Evid Synth 2019; 18:56-73. [PMID: 31453842 DOI: 10.11124/jbisrir-2017-003825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review was to synthesize the best available evidence on the effectiveness of the Manchester Triage System (MTS) on time to treatment (TtT) for patients who visit the emergency department (ED). INTRODUCTION The objectives of the MTS are to define a safe wait time for medical attention. Triage systems, such as the MTS, use criteria to ensure patient safety by determining appropriate wait times for each individual who visits the ED. The TtT is the time interval between arrival at the ED to initiation of therapeutic interventions. A short TtT is important in different clinical situations and may reduce infections and mortality. The MTS may have an impact on the TtT. INCLUSION CRITERIA This review considered studies that included any patients visiting the ED with any complaints or medical diagnoses who were triaged using the MTS by nurses or doctors, and the TtT was measured. This review considered randomized controlled trials, as well as quasi-experimental, before-and-after, case-control and analytical cross-sectional studies. Studies published after 1994 in English, Spanish, Portuguese, French and German were considered for inclusion. METHOD This systematic review was conducted in accordance with JBI methodology. The search strategy aimed to find both published and unpublished studies in MEDLINE, CINAHL, Lilacs, Web of Science, Embase, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, Banco de Teses - CAPES, and Digital Dissertations. The results of this search were assessed by one reviewer who excluded duplicate results. Titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria. The full texts of potentially eligible papers were retrieved and independently assessed by two reviewers using a standardized critical appraisal instrument from JBI. Data were extracted from studies included in the review and were presented using a narrative form. Tables were used to summarize the characteristics and findings of the studies. RESULTS The review included two before-and-after studies, with a total of 2265 participants. One study was of moderate quality, and the other was of high quality. One study included only patients with acute ischemic stroke, while the other included patients with any complaint. Both studies were performed with consecutive samples. The median TtT was 10 minutes before implementing the MTS and 12 minutes after implementing the MTS in the study that included patients with any complaints. In the study including patients with acute ischemic stroke, the median TtT decreased by 15 minutes after implementing the MTS (from 75 to 60 minutes). Because of the heterogeneity in the characteristics of the populations of the two studies, the results could not be pooled. CONCLUSIONS The MTS reduced the median TtT for patients triaged at the highest priority levels (orange and yellow), but it did not decrease the median TtT in all patients. The existing evidence base regarding the effectiveness of the MTS comes from two studies with methodological limitations that could not be pooled. The evidence indicates the MTS may confer benefit to some patients who visit the ED by reducing TtT, but not for all patients. Further research is needed before firm conclusions can be made.
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Affiliation(s)
| | - Fernanda Ayache Nishi
- University Hospital, University of São Paulo, São Paulo, Brazil.,The Brazilian Centre for Evidence-based Healthcare: a Joanna Briggs Institute Centre of Excellence
| | | | - Diná de Almeida Lopes Monteiro da Cruz
- The Brazilian Centre for Evidence-based Healthcare: a Joanna Briggs Institute Centre of Excellence.,School of Nursing, University of São Paulo, São Paulo, Brazil
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Zhang X, Kim J, Patzer RE, Pitts SR, Chokshi FH, Schrager JD. Advanced diagnostic imaging utilization during emergency department visits in the United States: A predictive modeling study for emergency department triage. PLoS One 2019; 14:e0214905. [PMID: 30964899 PMCID: PMC6456195 DOI: 10.1371/journal.pone.0214905] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/21/2019] [Indexed: 11/18/2022] Open
Abstract
Background Emergency department (ED) crowding is associated with negative health outcomes, patient dissatisfaction, and longer length of stay (LOS). The addition of advanced diagnostic imaging (ADI), namely CT, ultrasound (U/S), and MRI to ED encounter work up is a predictor of longer length of stay. Earlier and improved prediction of patients’ need for advanced imaging may improve overall ED efficiency. The aim of the study was to detect the association between ADI utilization and the structured and unstructured information immediately available during ED triage, and to develop and validate models to predict utilization of ADI during an ED encounter. Methods We used the United States National Hospital Ambulatory Medical Care Survey data from 2009 to 2014 to examine which sociodemographic and clinical factors immediately available at ED triage were associated with the utilization of CT, U/S, MRI, and multiple ADI during a patient’s ED stay. We used natural language processing (NLP) topic modeling to incorporate free-text reason for visit data available at time of ED triage in addition to other structured patient data to predict the use of ADI using multivariable logistic regression models. Results Among the 139,150 adult ED visits from a national probability sample of hospitals across the U.S, 21.9% resulted in ADI use, including 16.8% who had a CT, 3.6% who had an ultrasound, 0.4% who had an MRI, and 1.2% of the population who had multiple types of ADI. The c-statistic of the predictive models was greater than or equal to 0.78 for all imaging outcomes, and the addition of text-based reason for visit information improved the accuracy of all predictive models. Conclusions Patient information immediately available during ED triage can accurately predict the eventual use of advanced diagnostic imaging during an ED visit. Such models have the potential to be incorporated into the ED triage workflow in order to more rapidly identify patients who may require advanced imaging during their ED stay and assist with medical decision-making.
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Affiliation(s)
- Xingyu Zhang
- University of Michigan School of Nursing, Applied Biostatics Laboratory, Ann Arbor, MI, United States of America
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Joyce Kim
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Rachel E. Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, United States of America
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Stephen R. Pitts
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA, United States of America
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Falgun H. Chokshi
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Justin D. Schrager
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, United States of America
- * E-mail:
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16
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Do physicians and nurses agree on triage levels in the emergency department? A meta-analysis. Notf Rett Med 2019. [DOI: 10.1007/s10049-019-0580-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Bell A, Toloo GS, Crilly J, Burke J, Williams G, McCann B, FitzGerald G. Emergency department models of care in Queensland: a multisite cross-sectional study. AUST HEALTH REV 2019; 43:363-370. [DOI: 10.1071/ah17233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 03/26/2018] [Indexed: 11/23/2022]
Abstract
Objective
The acuity and number of presentations being made to emergency departments (EDs) is increasing. In an effort to safely and efficiently manage this increase and optimise patient outcomes, innovative models of care (MOC) have been implemented. What is not clear is how these MOC reflect the needs of patients or relate to each other or to ED performance. The aim of this study was to describe ED MOC in Queensland, Australia.
Methods
Situated within a larger mixed-methods study, the present study was a cross-sectional study. In early 2015, leaders (medical directors and nurse managers) from public hospital EDs in Queensland were invited to complete a survey detailing ED activity, staffing profiles, treatment space, MOC and National Emergency Access Target (NEAT) performance. Routinely collected ED information system data was also used.
Results
Twenty of the 27 EDs invited participated in the study (response rate 74%). An extensive array of MOC were identified that were categorised into those that facilitate input, throughput and output from the ED. There was no consistent evidence as to the relative effectiveness of these MOC in achieving ED performance benchmarks, such as NEAT performance.
Conclusion
There is considerable variability in the MOC used throughout EDs in Queensland. A more complete analysis of the relative effectiveness of different MOC either in isolation or as part of a comprehensive approach would help inform more consistent MOC in Queensland EDs.
What is known about the topic?
MOC in any given ED are implemented in response to factors such as the geographical location of the hospital, hospital-specific characteristics and service profile, staffing profile and patient demographic profile. In the era of time-based targets, they may also serve to address a particular aspect of flow in the face of rising ED demand. Although many of the MOC attempt to deal with flow in a linear fashion, target specific phases of the ED journey or address particular patient cohorts, what is clear is that not all EDs are shaped and formed the same.
What does this paper add?
The study provides a comprehensive description of the varied models of care operating within Queensland public hospital EDs and how they relate to ED performance. A basic taxonomy of contemporary ED MOC is necessary to allow comparison between departments and inform decisions regarding safety, efficiency and cost-effectiveness.
What are the implications to practitioners?
A contemporary understanding of the presence and profile of ED MOC that currently exist within a network of hospitals and health services is important for managers, clinicians and patients to inform decision-making regarding the safety, clinical effectiveness and cost-effectiveness of these models. This understanding can also inform where and how further improvements in care delivery can progress.
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Arbune A, Wackerbarth S, Allison P, Conigliaro J. Improvement through Small Cycles of Change: Lessons from an Academic Medical Center Emergency Department. J Healthc Qual 2018; 39:259-269. [PMID: 28858964 DOI: 10.1111/jhq.12078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article describes the experiences of a quality improvement team that used small cycles of change to improve the emergency department (ED) of an academic medical center. The role of EDs in the provision of healthcare continues to increase in importance. ED bottlenecks contribute to long waits and diminished outcomes for ED patients as well as more system-wide issues, such as inefficiencies in inpatient admission processes. The purpose of this "ED Operational Efficiency Project" was to reduce lengths of stay (LOS) for low-acuity patients. The team used lean management techniques to both improve services and shift the ED culture to prioritize continuous quality improvement. The goal to reduce LOS by 30% was met as the result of several inter=related projects (or small cycles of change). Key lessons include monitoring metrics, communicating with teams and target populations, learning from initial failures, using small wins to increase momentum, and anchoring changes.
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Abdulwahid MA, Turner J, Mason SM. Senior doctor triage (SDT), a qualitative study of clinicians' views on senior doctors' involvement in triage and early assessment of emergency patients. Emerg Med J 2018; 35:440-446. [PMID: 29748230 DOI: 10.1136/emermed-2017-207219] [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: 09/30/2017] [Revised: 04/03/2018] [Accepted: 04/24/2018] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Despite the focus during the last decade on introducing interventions such as senior doctor initial assessment or senior doctor triage (SDT) to reduce emergency department (ED) crowding, there has been little attempt to identify the views of emergency healthcare professionals on such interventions. The aim of this study was to gain an understanding of SDT from the perspective of emergency hospital staff. A secondary aim of this study was to develop a definition of SDT based on the interview findings and the available literature on this process. METHODS Qualitative semi-structured telephone interviews were conducted with participants of different backgrounds including senior doctors, nurses, paramedics and ED managers. Textual data were analysed using a template analysis approach. RESULTS 27 participants from 13 EDs across England were interviewed. SDT was viewed as a safety mechanism and a measure to control patient flow. The most prominent positive aspect was the ability to initiate early investigations and treatment. Various shortcomings of SDT were described such as the lack of standardisation of the process and its cost implications. Participants identified a number of barriers to this process including insufficient resources and exit block, and called for solutions focused on these issues. A proposed definition of an 'ideal' SDT was developed where it is described as a systematic brief assessment of patients arriving at the ED by a senior doctor-led team, which takes place in a dedicated unit. The aim of this assessment is to facilitate early investigation and management of patients, early patient disposition and guide junior staff to deliver safe and high-quality clinical care. CONCLUSION This is the first national study to explore the opinions of various emergency and managerial staff on the SDT model. It revealed variable interpretations of this model and what it can and cannot offer. This has led to a standard definition of the SDT process, which can be useful for clinicians and researchers in emergency care.
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Affiliation(s)
- Maysam Ali Abdulwahid
- Center for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Janette Turner
- Center for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Suzanne M Mason
- Center for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
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20
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Liu J, Masiello I, Ponzer S, Farrokhnia N. Can interprofessional teamwork reduce patient throughput times? A longitudinal single-centre study of three different triage processes at a Swedish emergency department. BMJ Open 2018; 8:e019744. [PMID: 29674366 PMCID: PMC5914774 DOI: 10.1136/bmjopen-2017-019744] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 03/08/2018] [Accepted: 03/14/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine the impact on emergency department (ED) throughput times and proportion of patients who leave without being seen by a physician (LWBS) of two triage interventions, where comprehensive nurse-led triage was first replaced by senior physician-led triage and then by interprofessional teamwork. DESIGN Single-centre before-and-after study. SETTING Adult ED of a Swedish urban hospital. PARTICIPANTS Patients arriving on weekdays 08:00 to 21:00 during three 1-year periods in the interval May 2012 to November 2015. A total of 185 806 arrivals were included. INTERVENTIONS Senior physicians replaced triage nurses May 2013 to May 2014. Interprofessional teamwork replaced the triage process on weekdays 08:00 to 21:00 November 2014 to November 2015. MAIN OUTCOME MEASURES Primary outcomes were the median time to physician (TTP) and the median length of stay (LOS). Secondary outcome was the LWBS rate. RESULTS The crude median LOS was shortest for teamwork, 228 min (95% CI 226.4 to 230.5) compared with 232 min (95% CI 230.8 to 233.9) for nurse-led and 250 min (95% CI 248.5 to 252.6) for physician-led triage. The adjusted LOS for the teamwork period was 16 min shorter than for nurse-led triage and 23 min shorter than for physician-led triage. The median TTP was shortest for physician-led triage, 56 min (95% CI 54.5 to 56.6) compared with 116 min (95% CI 114.4 to 117.5) for nurse-led triage and 74 min (95% CI 72.7 to 74.8) for teamwork. The LWBS rate was 1.9% for nurse-led triage, 1.2% for physician-led triage and 3.2% for teamwork. All outcome measure differences had two-tailed p values<0.01. CONCLUSIONS Interprofessional teamwork had the shortest length of stay, a shorter time to physician than nurse-led triage, but a higher LWBS rate. Interprofessional teamwork may be a useful approach to reducing ED throughput times.
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Affiliation(s)
- Jenny Liu
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Italo Masiello
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Sari Ponzer
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Nasim Farrokhnia
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
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21
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Magalhães ALP, Erdmann AL, Silva ELD, Santos JLGD. Lean thinking in health and nursing: an integrative literature review. Rev Lat Am Enfermagem 2017; 24:e2734. [PMID: 27508906 PMCID: PMC4990033 DOI: 10.1590/1518-8345.0979.2734] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 11/13/2015] [Indexed: 11/30/2022] Open
Abstract
Objectives: to demonstrate the scientific knowledge developed on lean thinking in health,
highlighting the impact and contributions in health care and nursing. Method: an integrative literature review in the PubMed, CINAHL, Scopus, Web of Science,
Emerald, LILACS and SciELO electronic library databases, from 2006 to 2014, with
syntax keywords for each data base, in which 47 articles were selected for
analysis. Results: the categories were developed from the quality triad proposed by Donabedian:
structure, process and outcome. Lean thinking is on the rise in health surveys,
particularly internationally, especially in the USA and UK, improving the
structure, process and outcome of care and management actions. However, it is an
emerging theme in nursing. Conclusion: this study showed that the use of lean thinking in the context of health has a
transforming effect on care and organizational aspects, promoting advantages in
terms of quality, safety and efficiency of health care and nursing focused on the
patient.
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Affiliation(s)
- Aline Lima Pestana Magalhães
- PhD, Adjunct Professor, Departamento de Enfermagem, Universidade do Estado de Santa Catarina, Chapecó, SC, Brazil
| | - Alacoque Lorenzini Erdmann
- PhD, Full Professor, Departamento de Enfermagem, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Elza Lima da Silva
- PhD, Adjunct Professor, Departamento de Enfermagem, Universidade Federal do Maranhão, Florianópolis, SC, Brazil
| | - José Luís Guedes Dos Santos
- PhD, Adjunct Professor, Departamento de Enfermagem, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
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22
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Weston V, Jain SK, Gottlieb M, Aldeen A, Gravenor S, Schmidt MJ, Malik S. Effectiveness of Resident Physicians as Triage Liaison Providers in an Academic Emergency Department. West J Emerg Med 2017; 18:577-584. [PMID: 28611876 PMCID: PMC5468061 DOI: 10.5811/westjem.2017.1.33243] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 12/18/2016] [Accepted: 01/30/2017] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Victoria Weston
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Sushil K Jain
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
| | - Amer Aldeen
- Center for Emergency Medical Education, US Acute Care Solutions, Chicago, Illinois
| | - Stephanie Gravenor
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Michael J Schmidt
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Sanjeev Malik
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
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Yarmohammadian MH, Rezaei F, Haghshenas A, Tavakoli N. Overcrowding in emergency departments: A review of strategies to decrease future challenges. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2017; 22:23. [PMID: 28413420 PMCID: PMC5377968 DOI: 10.4103/1735-1995.200277] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/07/2016] [Accepted: 11/29/2016] [Indexed: 01/20/2023]
Abstract
Emergency departments (EDs) are the most challenging ward with respect to patient delay. The goal of this study is to present strategies that have proven to reduce delay and overcrowding in EDs. In this review article, initial electronic database search resulted in a total of 1006 articles. Thirty articles were included after reviewing full texts. Inclusion criteria were assessments of real patient flows and implementing strategies inside the hospitals. In this study, we discussed strategies of team triage, point-of-care testing, ideal ED patient journey models, streaming, and fast track. Patients might be directed to different streaming channels depending on clinical status and required practitioners. The most comprehensive strategy is ideal ED patient journey models, in which ten interrelated substrategies are provided. ED leaders should apply strategies that provide a continuous care process without deeply depending on external services.
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Affiliation(s)
- Mohammad H Yarmohammadian
- Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Rezaei
- Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abbas Haghshenas
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Nahid Tavakoli
- Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran
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Can Team Triage Improve Patient Flow in the Emergency Department? A Systematic Review and Meta-Analysis. Adv Emerg Nurs J 2017; 38:233-50. [PMID: 27482995 DOI: 10.1097/tme.0000000000000113] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This systematic review was performed as a feasibility study for revamping the triage service of an emergency department (ED) in a district hospital. In view of the overcrowding problem that plagues EDs worldwide, we reviewed evidence from randomized controlled trials (RCTs) to determine whether ED team triage improves patient flow in comparison with single-nurse triage. We measured improvement in patient flow in terms of the reduction in length of stay (LOS) or wait time (WT) for all ED patients. Adopting the Cochrane methodology, we searched and evaluated data sources for RCTs comparing patients assessed by an ED triage team, with patients receiving single-nurse triage at the same site. The data extracted were independently reviewed by 2 authors for inclusion and quality assessment. As for risk of bias across studies, there was an overall assessment of every outcome across the included studies according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria for RCTs. In total, 2,164 studies were identified and 2,106 were excluded on the basis of title/abstract, leaving 58 articles for full assessment. Four trials (all cluster RCTs) involving 14,772 patients (165 clusters) met the inclusion criteria. On the basis of our analysis, there was no statistically significant or clinically relevant reduction of LOS and WT for all patients in these studies. One study reported death as an outcome: Relative risk was 0.34 (95% CI [0.01, 8.24]), which suggested that team triage might reduce mortality. Overall, although we have found no conclusive evidence from RCTs to support the use of team triage for improving patient flow in the ED, the results need not deter nursing managers intending to introduce team triage for improving the morale of the triage nurse. However, they may need to consider economic and organizational factors, such as resource reallocation and staff receptiveness, in implementing the new practice.
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Abstract
OBJECTIVE To study the operational impact of process improvements on emergency department (ED) patient flow. The changes did not require any increase in resources or expenditures. METHODS This was a 36-month pre- and post-intervention study to evaluate the effect of implementing process improvements at a community ED from January 2010 to December 2012. The intervention comprised streamlining triage by having patients accepted into internal waiting areas immediately after triage. Within the ED, parallel processes unfolded, and there was no restriction on when registration occurred or which health care provider a patient saw first. Flexible nursing ratios allowed nursing staff to redeploy and move to areas of highest demand. Last, demand-based physician scheduling was implemented. The main outcome was length of stay (LOS). Secondary outcomes included time to physician initial assessment (PIA), left-without-being-seen (LWBS) rates, and left-against-medical-advice (LAMA) rates. Segmented regression of interrupted time series analysis was performed to quantify the impact of the intervention, and whether it was sustained. RESULTS Patients totalling 251,899 attended the ED during the study period. Daily patient volumes increased 17.3% during the post-intervention period. Post-intervention, mean LOS decreased by 0.64 hours (p<0.005). LOS for non-admitted Canadian Triage and Acuity Scale 2 (-0.58 hours, p<0.005), 3 (-0.75 hours, p<0.005), and 4 (-0.32 hours, p<0.005) patients also decreased. There were reductions in PIA (43.81 minutes, p<0.005), LWBS (35.2%, p<0.005), and LAMA (61.9%, p<0.005). CONCLUSION A combination of process improvements in the ED was associated with clinically significant reductions in LOS, PIA, LWBS, and LAMA for non-resuscitative patients.
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Begaz T, Elashoff D, Grogan TR, Talan D, Taira BR. Initiating Diagnostic Studies on Patients With Abdominal Pain in the Waiting Room Decreases Time Spent in an Emergency Department Bed: A Randomized Controlled Trial. Ann Emerg Med 2016; 69:298-307. [PMID: 27527398 DOI: 10.1016/j.annemergmed.2016.06.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 06/04/2016] [Accepted: 06/23/2016] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE The effect of clinician screening of patients in the emergency department (ED) waiting room is unclear. This study aims to determine the effect of initiating laboratory and imaging studies from the ED waiting room on time in a bed, total ED time, and likelihood of patients leaving before completion of service. METHODS This was a prospective, randomized, controlled trial evaluating 1,659 nonpregnant adults with a chief complaint of abdominal pain, conducted in a public hospital ED when all ED beds were occupied and patients were in the waiting room awaiting definitive evaluation. After a brief screening examination, stable patients were randomized to either rapid medical evaluation (RME)+waiting room diagnostic testing (WRDT) or RME-only groups. Patients randomized to the RME+WRDT group had laboratory and imaging studies ordered at the discretion of the screening provider while in the waiting room. The primary outcome was time in an ED bed. Secondary outcomes were total ED time and rate of leaving before completion of service. Linear and logistic regression models were used to compare outcomes between groups. RESULTS Between July 2014 and May 2015, 1,659 patients completed the study, 848 patients in the RME+WRDT group and 811 in the RME-only group. Baseline demographic characteristics were similar between groups. Patients in the RME+WRDT group had a significantly shorter mean time in an ED bed than the RME-only group, 245 minutes compared with 277 minutes (adjusted difference of 31 minutes; 95% confidence interval [CI] 16 to 46 minutes). The RME+WRDT group also had significantly shorter mean total ED time from arrival to disposition than the RME-only group, 460 minutes compared with 504 minutes (adjusted difference 42 minutes; 95% CI 22 to 63 minutes). Of the 1,659 patients enrolled, 181 left before completion of service: 78 of 848 patients (9%) in the RME+WRDT group compared with 103 of 811 (13%) in the RME-only group (difference 3.5%; 95% CI 0.5% to 6.5%). By the end of their ED visit, patients in the RME+WRDT group had significantly more types of diagnostic studies ordered than those in the RME-only group, 2.59 versus 2.03 total unique test categories by location ordered (difference 0.56; 95% CI 0.44 to 0.68). CONCLUSION Initiating diagnostic testing in the waiting room reduced time spent in an ED bed, total ED time, and rates of leaving before completion of service. For clinicians screening patients in the waiting room, initiating diagnostic evaluations may improve throughput in crowded EDs.
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Affiliation(s)
- Tomer Begaz
- Department of Emergency Medicine, David Geffen School of Medicine, Olive View-UCLA Emergency Medicine, Sylmar, CA.
| | - David Elashoff
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Tristan R Grogan
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - David Talan
- Department of Emergency Medicine, David Geffen School of Medicine, Olive View-UCLA Emergency Medicine, Sylmar, CA
| | - Breena R Taira
- Department of Emergency Medicine, David Geffen School of Medicine, Olive View-UCLA Emergency Medicine, Sylmar, CA
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27
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Husebø SE, Olsen ØE. Impact of clinical leadership in teams' course on quality, efficiency, responsiveness and trust in the emergency department: study protocol of a trailing research study. BMJ Open 2016; 6:e011899. [PMID: 27515758 PMCID: PMC4985869 DOI: 10.1136/bmjopen-2016-011899] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Clinical leadership has long been recognised as critical for optimising patient safety, quality of care and interprofessional teamwork in busy and stressful healthcare settings. There is a need to compensate for the absence of the conventional mentor-to-apprentice transfer of clinical leadership knowledge and skills. While young doctors and nurses are increasingly proficient in medical, surgical and technical skills, their training in, and knowledge of clinical leadership skills, is not adequate to meet the demands for these non-technical skills in the emergency department. Thus, the purpose of the paper is to present and discuss the study protocol of clinical leadership in a course for teams that aims to improve quality, efficiency, responsiveness of healthcare services and collegial trust in the emergency department. METHODS AND ANALYSIS The study employs a trailing research design using multiple quantitative and qualitative methods in the summative (pretest and post-test) and formative evaluation. Quantitative data have been collected from a patient questionnaire, the emergency departments' database and by the observation of team performance. Qualitative data have been collected by shadowing healthcare professionals and through focus group interviews. To ensure trustworthiness in the data analysis, we will apply member checks and analyst triangulation, in addition to providing contextual and sample description to allow for evaluation of transferability of our results to other contexts and groups. ETHICS AND DISSEMINATION The study is approved by the ethics committee of the western part of Norway and the hospital. The study is based on voluntary participation and informed written consent. Informants can withdraw at any point in time. The results will be disseminated at research conferences, peer review journals and through public presentations to people outside the scientific community.
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Affiliation(s)
- Sissel Eikeland Husebø
- Department of Health Studies, Faculty of Social Science, University of Stavanger, Stavanger, Norway
- Department of Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Øystein Evjen Olsen
- Emergency Department, Stavanger University Hospital, Stavanger, Norway
- Global Health Priorities Research Group, Department of Global Public Health and Primary Care, Center for International Health, University of Bergen, Bergen, Norway
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Ebrahimi M, Mirhaghi A, Mazlom R, Heydari A, Nassehi A, Jafari M. The Role Descriptions of Triage Nurse in Emergency Department: A Delphi Study. SCIENTIFICA 2016; 2016:5269815. [PMID: 27382500 PMCID: PMC4921622 DOI: 10.1155/2016/5269815] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 04/19/2016] [Indexed: 05/29/2023]
Abstract
Background. Triage nurses play a pivotal role in the emergency department. However some researchers have attempted to expand triage nurse's role; remarkable discrepancies exist among scholarly communities. The aim was to develop a role description of triage nurse relying on the experts. Methods. A modified Delphi study consisting of 3 rounds was performed from March to October 2014. In the first round, an extensive review of the literature was conducted. Expert selection was conducted through a purposeful sample of 38 emergency medicine experts. Results. Response rates for the second and third rounds were 37% and 58%. Average age of panelists was (38.42 ± 5.94) years. Thirty-nine out of 54 items reached to the final round. Prioritizing had the higher agreement rate and least agreement on triage related interventions. Conclusion. Triage nursing as a relatively new role for nurses needs significant development to be practiced. Comprehensive educational programs and developmental research are required to support diagnostic and therapeutic interventions in triage practice by nurses.
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Affiliation(s)
- Mohsen Ebrahimi
- Department of Emergency Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad 9137913316, Iran
| | - Amir Mirhaghi
- Evidence-Based Caring Research Center, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad 9137913199, Iran
| | - Reza Mazlom
- Evidence-Based Caring Research Center, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad 9137913199, Iran
| | - Abbas Heydari
- Evidence-Based Caring Research Center, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad 9137913199, Iran
| | - Asra Nassehi
- Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman 7616913555, Iran
| | - Mojtaba Jafari
- Department of Medical-Surgical Nursing, Faculty of Nursing and Midwifery, Bam University of Medical Sciences, Khalije Fars Boulevard, Bam, Kerman 7661771967, Iran
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Burström L, Engström ML, Castrén M, Wiklund T, Enlund M. Improved quality and efficiency after the introduction of physician-led team triage in an emergency department. Ups J Med Sci 2016; 121:38-44. [PMID: 26553523 PMCID: PMC4812056 DOI: 10.3109/03009734.2015.1100223] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Overcrowding in the emergency department (ED) may negatively affect patient outcomes, so different triage models have been introduced to improve performance. Physician-led team triage obtains better results than other triage models. We compared efficiency and quality measures before and after reorganization of the triage model in the ED at our county hospital. MATERIALS AND METHODS We retrospectively compared two study periods with different triage models: nurse triage in 2008 (baseline) and physician-led team triage in 2012 (follow-up). Physician-led team triage was in use during day-time and early evenings on weekdays. Data were collected from electronic medical charts and the National Mortality Register. RESULTS We included 20,073 attendances in 2008 and 23,765 in 2012. The time from registration to physician presentation decreased from 80 to 33 min (P < 0.001), and the length of stay decreased from 219 to 185 min (P < 0.001) from 2008 to 2012, respectively. All of the quality variables differed significantly between the two periods, with better results in 2012. The odds ratio for patients who left before being seen or before treatment was completed was 0.62 (95% confidence interval 0.54-0.72). The corresponding result for unscheduled returns was 0.36 (0.32-0.40), and for the mortality rates within 7 and 30 days 0.72 (0.59-0.88) and 0.84 (0.73-0.97), respectively. The admission rate was 37% at baseline and 32% at follow-up (P < 0.001). CONCLUSION Physician-led team triage improved the efficiency and quality in EDs.
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Affiliation(s)
- Lena Burström
- Centre for Clinical Research, Uppsala University, Västmanlands County Hospital, Västerås, Sweden
- Lena Burström, PhD Centre for Clinical Research, Uppsala University, Västmanlands County Hospital, Västerås, Sweden
| | - Marie-Louise Engström
- Centre for Clinical Research, Uppsala University, Västmanlands County Hospital, Västerås, Sweden
| | | | - Tony Wiklund
- Centre for Clinical Research, Uppsala University, Västmanlands County Hospital, Västerås, Sweden
| | - Mats Enlund
- Centre for Clinical Research, Uppsala University, Västmanlands County Hospital, Västerås, Sweden
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Abdulwahid MA, Booth A, Kuczawski M, Mason SM. The impact of senior doctor assessment at triage on emergency department performance measures: systematic review and meta-analysis of comparative studies. Emerg Med J 2015; 33:504-13. [PMID: 26183598 DOI: 10.1136/emermed-2014-204388] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 06/22/2015] [Indexed: 11/03/2022]
Abstract
STUDY QUESTION To determine if placing a senior doctor at triage versus standard single nurse in a hospital emergency department (ED) improves ED performance by reviewing evidence from comparative design studies using several quality indicators. DESIGN Systematic review. DATA SOURCES Cochrane Library, MEDLINE, EMBASE, CINAHL, Cochrane Effective Practice and Organisation of Care (EPOC), Web of Science, Clinical Trials Registry website. In addition, references from included studies and citation searches were used to identify relevant studies. REVIEW METHODS Databases were searched for comparative studies examining the role of senior doctor triage (SDT), published from 1994 to 2014. Senior doctor was defined as a qualified medical doctor who completed high specialty training in emergency medicine. Articles with a primary aim to investigate the effect of SDT on ED quality indicators such as waiting time (WT), length of stay (LOS), left without being seen (LWBS) and left without treatment complete (LWTC) were included. Articles examining the adverse events and cost associated with SDT were also included. Only studies with a control group, either in a randomised controlled trial (RCT) or in an observational study with historical controls, were included. The systematic literature search was followed by assessment of relevance and risk of bias in each individual study fulfilling the inclusion criteria using the Effective Public Health Practice Project (EPHPP) bias tool. Data extraction was based on a form designed and piloted by the authors for dichotomous and continuous data. DATA SYNTHESIS Narrative synthesis and meta-analysis of homogenous data were performed. RESULTS Of 4506 articles identified, 25 relevant studies were retrieved; 12 were of the weak pre-post study design, 9 were of moderate quality and 4 were of strong quality. The majority of the studies revealed improvements in ED performance measures favouring SDT. Pooled results from two Canadian RCTs showed a significant reduction in LOS of medium acuity patients (weighted means difference (WMD) -26.26 min, 95% CI -38.50 to -14.01). Another two RCTs revealed a significant reduction in WT (WMD -26.17 min, 95% CI -31.68 to -20.65). LWBS was reduced in two Canadian RCTs (risk ratio (RR)=0.79, 95% CI 0.66 to 0.94). This was echoed by the majority of pre-post study designs. SDT did not change the occurrence of adverse events. No clear benefit of SDT in terms of patient satisfaction or cost effectiveness could be identified. CONCLUSIONS This review demonstrates that SDT can be an effective measure to enhance ED performance, although cost versus benefit analysis is needed. The potential high risk of bias in the evidence identified, however, mandates more robust multicentred studies to confirm these findings.
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Affiliation(s)
- Maysam Ali Abdulwahid
- School of Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK
| | - Maxine Kuczawski
- School of Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK
| | - Suzanne M Mason
- School of Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK
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Holden RJ, Eriksson A, Andreasson J, Williamsson A, Dellve L. Healthcare workers' perceptions of lean: a context-sensitive, mixed methods study in three Swedish hospitals. APPLIED ERGONOMICS 2015; 47:181-192. [PMID: 25479987 PMCID: PMC4258221 DOI: 10.1016/j.apergo.2014.09.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 09/08/2014] [Accepted: 09/08/2014] [Indexed: 06/04/2023]
Abstract
As the application of lean in healthcare expands, further research is needed in at least two areas: first, on the role of context in shaping lean and its consequences and second, on how healthcare workers perceive lean. Accordingly, this context-sensitive, mixed methods study addressed how hospital workers' perceptions of lean varied across contexts in three Swedish hospitals. Registered nurses and physicians at the hospitals and across units differing in acuity completed standardized surveys (N = 236, 57% response rate) about their perceptions of hospital-wide lean implementation. Perceptions varied by: hospital context, with one hospital's employees reporting the least favorable perceptions; unit acuity, with higher-acuity units reporting more favorable perceptions; and professional role, with nurses reporting more favorable perceptions than physicians. Individual interviews, group interviews, and observations provided insight about these dissimilar contexts and possible explanations for context-specific variability. Findings are discussed with respect to strategies for implementing lean in healthcare; the importance of attending to levels, context, and worker consequences of lean; and directions for future research.
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Affiliation(s)
- Richard J Holden
- Department of BioHealth Informatics, Indiana University School of Informatics and Computing, Indianapolis, IN, USA; Center for Health Informatics Research & Innovation (CHIRI), Indianapolis, IN, USA.
| | - Andrea Eriksson
- School of Technology and Health, Royal Institute of Technology (KTH), Stockholm, Sweden
| | - Jörgen Andreasson
- School of Technology and Health, Royal Institute of Technology (KTH), Stockholm, Sweden; School of Health Sciences, University of Borås, Sweden
| | - Anna Williamsson
- School of Technology and Health, Royal Institute of Technology (KTH), Stockholm, Sweden
| | - Lotta Dellve
- School of Technology and Health, Royal Institute of Technology (KTH), Stockholm, Sweden; School of Health Sciences, University of Borås, Sweden
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Barata I, Brown KM, Fitzmaurice L, Griffin ES, Snow SK. Best practices for improving flow and care of pediatric patients in the emergency department. Pediatrics 2015; 135:e273-83. [PMID: 25548334 DOI: 10.1542/peds.2014-3425] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This report provides a summary of best practices for improving flow, reducing waiting times, and improving the quality of care of pediatric patients in the emergency department.
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Nestler DM, Halasy MP, Fratzke AR, Church CJ, Scanlan-Hanson LN, Lohse CM, Campbell RL, Sadosty AT, Hess EP. Patient throughput benefits of triage liaison providers are lost in a resource-neutral model: a prospective trial. Acad Emerg Med 2014; 21:794-8. [PMID: 24916989 DOI: 10.1111/acem.12416] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 02/09/2014] [Accepted: 02/28/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Patient throughput is an increasingly important cause of emergency department (ED) crowding. The authors previously reported shorter patient length of stay (LOS) when adding a triage liaison provider, which required additional personnel. Here, the objective was to evaluate the effect of moving a fast-track provider to the triage liaison role. METHODS This was a prospective observational before-and-after study design with predefined outcomes measures. A "standard staffing" situation (where an advanced practice provider staffed treatment rooms in the fast track) was compared with an advanced practice provider performing the triage liaison staffing role, with no additional staff. Eleven intervention ("triage liaison staffing") days were compared with 11 matched control ("standard staffing") days immediately preceding the intervention. Total LOS was measured for all adult Emergency Severity Index (ESI) 3, 4, and 5 patients (excluding behavioral health patients), and results were compared using Wilcoxon rank-sum and chi-square tests. RESULTS A total of 681 patients registered on control days and 599 on intervention days. There was no significant difference in total patient LOS: median = 273 minutes, interquartile range (IQR) 176 to 384 minutes on intervention days versus median = 253 minutes, IQR = 175 to 365 minutes on control days (p = 0.20). There was no difference in left-without-being-seen (LWBS) rates (n = 48, 7% on control days vs. n = 35, 6% on intervention days; p=0.38). Secondary analysis of only ESI 3 patients showed no difference in total LOS between periods (median = 284 minutes, IQR = 194 to 396 minutes on intervention days vs. median = 290 minutes, IQR = 217 to 397 minutes on control days; p = 0.22). There was, however, significantly greater total LOS for ESI 4 and 5 patients during the intervention period (median = 238 minutes, IQR = 124 to 350 minutes on intervention days vs. median = 192 minutes, IQR = 124 to 256 minutes on control days; p = 0.011). CONCLUSIONS The previously reported benefits on patient LOS and LWBS rates after adding a triage liaison (resource additive) were lost when that provider was moved from fast track to the triage role (resource neutral). While the triage liaison provider role may be a way to improve ED throughput when additional resources are available, as evidenced by our prior study, the triage liaison model itself does not appear to replace the staffing of treatment rooms, as evidenced by this study.
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Affiliation(s)
- David M. Nestler
- Department of Emergency Medicine; Mayo Clinic College of Medicine; Rochester MN
| | - Michael P. Halasy
- Department of Emergency Medicine; Mayo Clinic College of Medicine; Rochester MN
| | - Alesia R. Fratzke
- Department of Emergency Medicine; Mayo Clinic College of Medicine; Rochester MN
| | | | | | - Christine M. Lohse
- Department of Biomedical Statistics and Informatics; Mayo Clinic College of Medicine; Rochester MN
| | - Ronna L. Campbell
- Department of Emergency Medicine; Mayo Clinic College of Medicine; Rochester MN
| | - Annie T. Sadosty
- Department of Emergency Medicine; Mayo Clinic College of Medicine; Rochester MN
| | - Erik P. Hess
- Department of Emergency Medicine; Mayo Clinic College of Medicine; Rochester MN
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Burström L, Starrin B, Engström ML, Thulesius H. Waiting management at the emergency department - a grounded theory study. BMC Health Serv Res 2013; 13:95. [PMID: 23496853 PMCID: PMC3626711 DOI: 10.1186/1472-6963-13-95] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 03/04/2013] [Indexed: 12/30/2022] Open
Abstract
Background An emergency department (ED) should offer timely care for acutely ill or injured persons that require the attention of specialized nurses and physicians. This study was aimed at exploring what is actually going on at an ED. Methods Qualitative data was collected 2009 to 2011 at one Swedish ED (ED1) with 53.000 yearly visits serving a population of 251.000. Constant comparative analysis according to classic grounded theory was applied to both focus group interviews with ED1 staff, participant observation data, and literature data. Quantitative data from ED1 and two other Swedish EDs were later analyzed and compared with the qualitative data. Results The main driver of the ED staff in this study was to reduce non-acceptable waiting. Signs of non-acceptable waiting are physical densification, contact seeking, and the emergence of critical situations. The staff reacts with frustration, shame, and eventually resignation when they cannot reduce non-acceptable waiting. Waiting management resolves the problems and is done either by reducing actual waiting time by increasing throughput of patient flow through structure pushing and shuffling around patients, or by changing the experience of waiting by calming patients and feinting maneuvers to cover up. Conclusion To manage non-acceptable waiting is a driving force behind much of the staff behavior at an ED. Waiting management is done either by increasing throughput of patient flow or by changing the waiting experience.
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Affiliation(s)
- Lena Burström
- Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
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