Impact of employing primary healthcare professionals in emergency department triage on patient flow outcomes: a systematic review and meta-analysis

Abstract

ObjectivesTo identify, critically appraise and summarise evidence on the impact of employing primary healthcare professionals (PHCPs: family physicians/general practitioners (GPs), nurse practitioners (NP) and nurses with increased authority) in the emergency department (ED) triage, on patient flow outcomes.MethodsWe searched Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) (inception to January 2020). Our primary outcome was the time to provider initial assessment (PIA). Secondary outcomes included time to triage, proportion of patients leaving without being seen (LWBS), length of stay (ED LOS), proportion of patients leaving against medical advice (LAMA), number of repeat ED visits and patient satisfaction. Two independent reviewers selected studies, extracted data and assessed study quality using the National Institute for Health and Care Excellence quality assessment tool.ResultsFrom 23 973 records, 40 comparative studies including 10 randomised controlled trials (RCTs) and 13 pre–post studies were included. PHCP interventions were led by NP (n=14), GP (n=3) or nurses with increased authority (n=23) at triage. In all studies, PHCP-led intervention effectiveness was compared with the traditional nurse-led triage model. Median duration of the interventions was 6 months. Study quality was generally low (confounding bias); 7 RCTs were classified as moderate quality. Most studies reported that PHCP-led triage interventions decreased the PIA (13/14), ED LOS (29/30), proportion of patients LWBS (8/10), time to triage (3/3) and repeat ED visits (5/6), and increased the patient satisfaction (8/10). The proportion of patients LAMA did not differ between groups (3/3). Evidence from RCTs (n=8) as well as other study designs showed a significant decrease in ED LOS favouring the PHCP-led interventions.ConclusionsOverall, PHCP-led triage interventions improved ED patient flow metrics. There was a significant decrease in ED LOS irrespective of the study design, favouring the PHCP-led interventions. Evidence from well-designed high-quality RCTs is required prior to widespread implementation.PROSPERO registration numberCRD42020148053.

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

“…4 We established analogy by evaluating similar adult and pediatric literature that show improvement in ED flow and patient outcomes with PIT evaluations. 18–20 Finally, we observed changes to the outcomes during periods when P-PIT was turned on and off. This finding fulfilled the Bradford-Hill criterion of experiment as we saw increased time to sepsis recognition during the pause and improvement after reinstating the intervention.…”

“…Our study further adds to the evidence that attending physician exams in triage are important for improving patient care and ED workflow. [18][19][20] Timely and effective ED throughput serve as markers of hospital system quality in metrics collected by the Centers for Medicaid and Medicare services. 22 One study of pediatric patients who left before being seen suggests that 5% were triaged as emergent and 31% as urgent.…”

Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence

“…Employing primary healthcare professionals (i.e. family physicians/general practitioners, nurse practitioners and nurses with increased authority) may be useful extension of triage team [18]. Discussion about replacing a triage nurse by a physician has no evidence to suggest that physicians are any better or more cost effective at triage than experienced nurses [17,19].…”

Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence

“…Triage systems usually rely on an experienced triage nurse to undertake triage [ 17 ]. Employing primary healthcare professionals (i.e., general or nurse practitioners) may be a useful extension of the triage team [ 18 ]. Discussion about replacing a triage nurse with a physician has no evidence to suggest that physicians are any better or more cost-effective at triage than experienced nurses [ 17 , 19 ].…”