Impact of a Triage Liaison Physician on Emergency Department Overcrowding and Throughput: A Randomized Controlled Trial

Holroyd, Brian R.; Bullard, Michael J.; Latoszek, K.; Gordon, Debbie; Allen, Sheri; Tam, Siulin; Blitz, Sandra; Yoon, Philip W.; Rowe, Brian H.

doi:10.1111/j.1553-2712.2007.tb01864.x

Cited by 108 publications

(81 citation statements)

References 17 publications

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“…It is a single-center study, and one of two randomized control trials [20]. To increase its generalizability from academic tertiary level centers, a multi-center trial is recommended.…”

Section: Discussionmentioning

confidence: 99%

“…Its role is to interact and start interventions on patients without an ED care space after interacting with the triage nurse. At least 10 studies testing the impact of adding a physician to the existing nurse at triage have shown some benefit [17-26] but only one of these was a randomized trial [20]. We modified an Australian model of physician-triage and report the evaluation of a MDRNSTAT.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Implementing wait-time reductions under Ontario government benchmarks (Pay-for-Results): a Cluster Randomized Trial of the Effect of a Physician-Nurse Supplementary Triage Assistance team (MDRNSTAT) on emergency department patient wait times

et al. 2013

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BackgroundInternationally, emergency departments are struggling with crowding and its associated morbidity, mortality, and decreased patient and health-care worker satisfaction. The objective was to evaluate the addition of a MDRNSTAT (Physician (MD)-Nurse (RN) Supplementary Team At Triage) on emergency department patient flow and quality of care.MethodsPragmatic cluster randomized trial. From 131 weekday shifts (8:00–14:30) during a 26-week period, we randomized 65 days (3173 visits) to the intervention cluster with a MDRNSTAT presence, and 66 days (3163 visits) to the nurse-only triage control cluster. The primary outcome was emergency department length-of-stay (EDLOS) for patients managed and discharged only by the emergency department. Secondary outcomes included EDLOS for patients initially seen by the emergency department, and subsequently consulted and admitted, patients reaching government-mandated thresholds, time to initial physician assessment, left-without being seen rate, time to investigation, and measurement of harm.ResultsThe intervention’s median EDLOS for discharged, non-consulted, high acuity patients was 4:05 [95th% CI: 3:58 to 4:15] versus 4:29 [95th% CI: 4:19–4:38] during comparator shifts. The intervention’s median EDLOS for discharged, non-consulted, low acuity patients was 1:55 [95th% CI: 1:48 to 2:05] versus 2:08 [95th% CI: 2:02–2:14]. The intervention’s median physician initial assessment time was 0:55 [95th% CI: 0:53 to 0:58] versus 1:21 [95th% CI: 1:18 to 1:25]. The intervention’s left-without-being-seen rate was 1.5% versus 2.2% for the control (p = 0.06). The MDRNSTAT subgroup analysis resulted in significant decreases in median EDLOS for discharged, non-consulted high (4:01 [95th% CI: 3:43–4:16]) and low acuity patients (1:10 95th% CI: 0:58–1:19]), as well as physician initial assessment time (0:25 [95th% CI: 0:23–0:26]). No patients returned to the emergency department after being discharged by the MDRNSTAT at triage.ConclusionsThe intervention reduced delays and left-without-being-seen rate without increased return visits or jeopardizing urgent care of severely ill patients.Trial registration numberNCT00991471 ClinicalTrials.gov

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“…It is a single-center study, and one of two randomized control trials [20]. To increase its generalizability from academic tertiary level centers, a multi-center trial is recommended.…”

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Implementing wait-time reductions under Ontario government benchmarks (Pay-for-Results): a Cluster Randomized Trial of the Effect of a Physician-Nurse Supplementary Triage Assistance team (MDRNSTAT) on emergency department patient wait times

et al. 2013

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“…Emergency department (ED) crowding, in which patient care cannot be provided within a reasonable time due to excess demand for emergency services, is a serious and challenging problem [1], [2]. In Japan, 13,100 patients in critical condition experienced an ambulance diversion more than four times during one ambulance transportation; about 21% of these ambulance diversions were caused by ED crowding [3].…”

Section: Introductionmentioning

confidence: 99%

Adding More Junior Residents May Worsen Emergency Department Crowding

2014

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BackgroundAlthough increasing staff numbers during shifts when emergency department (ED) crowding is severe can help meet patient demand, it remains unclear how different types of added staff, particularly junior residents, may affect crowding.MethodsTo identify associations between types of staff and ED crowding, we conducted a cross-sectional, single-center study in the ED of a large, teaching hospital in Japan between January and December 2012. Patients who visited the ED during the study period were enrolled. We excluded (1) patients previously scheduled to visit the ED, and (2) neonates transferred from other hospitals. During the study period, 27,970 patients were enrolled. Types of staff analyzed were junior (first and second year) residents, senior (third to fifth year) residents, attending (board-certified) physicians, and nurses. A generalized linear model was applied to length of ED stay for all patients as well as admitted and discharged patients to quantify an association with the additional staff.ResultsIn the model, addition of one attending physician or senior resident was associated with decreased length of ED stay for total patients by 3.88 or 1.64 minutes, respectively (95% CI, 2.20–5.56 and 0.81–2.48 minutes); while additional nursing staff had no association. Surprisingly, however, one additional junior resident was associated with prolonged length of ED stay for total patients by 0.97 minutes (95% CI 0.37–1.57 minutes) and for discharged patients by 1.01 minutes (95% CI 0.45–1.59 minutes).ConclusionStaffing adjustments aimed at alleviating ED crowding should focus on adding more senior staff during peak-volume shifts.

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“…In a previous study using this same model [12] there was improvement in time to physician evaluation and reduction in length of stay (LOS) and time on diversion following the addition of a physician in triage. In three similar models to the research site, Han et al [4] , Partovi et al [5] , and Holroyd et al [6] showed a reduction in overall LOS and number of patients leaving without being seen (LWBS). In two studies from the United Kingdom, Terris et al [7] noted a reduction in number of patients waiting to be seen at any one time utilizing a physician in triage while Subash et al [10] showed that team triage for three hours a day reduced time to see a doctor and time to radiology during the time of intervention but not for the remainder of the day.…”

Section: Discussionmentioning

confidence: 99%

“…studies in the literature that have investigated the use of a physician in triage [4][5][6][7][8][9][10][11][12] . The majority of these studies have focused on patient flow metrics for measured outcomes.…”

mentioning

confidence: 99%

Improving patient satisfaction by adding a physician in triage

Imperato

Morris

Sánchez

et al. 2013

JHA

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Background: The physician in triage (PIT) model has been proposed as a process improvement to help increase efficiency in the Emergency Department setting. However, its effect on patient satisfaction has not been well established.Methods: An interventional study comparing patient satisfaction scores for the 6-month period before and after implementation of a physician in triage model. In our system an additional attending physician was assigned to triage from 1 p.m. to 9 p.m. daily. Outcome measures were mean scores obtained from respondents to Press Ganey® patient satisfaction surveys for selected questions most likely to be impacted by PIT implementation and those included in the physician section of the survey.Results: Five hundred and eight respondents seen in the six months before the initiation of the PIT team and 458 respondents in the six months after the system change were included in the study. Improvement was noted in the absolute Press Ganey® scores in the Post-PIT time period across all questions analyzed with statistically significant differences noted for 8 of the 10 questions studied. Conclusions:Although seemingly small there was a statistically significant improvement in the absolute patient satisfaction scores after adding a physician in triage. Because small gains in absolute scores can result in large improvements on the percentile rank when using Press Ganey® surveys, physician in triage may be of significant benefit to overall patient satisfaction.

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Impact of a Triage Liaison Physician on Emergency Department Overcrowding and Throughput: A Randomized Controlled Trial

Abstract: A TLP improved important outcomes in an overcrowded ED and could improve delivery of emergency medical care in similar tertiary care EDs.

Cited by 108 publications

References 17 publications

Implementing wait-time reductions under Ontario government benchmarks (Pay-for-Results): a Cluster Randomized Trial of the Effect of a Physician-Nurse Supplementary Triage Assistance team (MDRNSTAT) on emergency department patient wait times

Implementing wait-time reductions under Ontario government benchmarks (Pay-for-Results): a Cluster Randomized Trial of the Effect of a Physician-Nurse Supplementary Triage Assistance team (MDRNSTAT) on emergency department patient wait times

Adding More Junior Residents May Worsen Emergency Department Crowding

Improving patient satisfaction by adding a physician in triage

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