Improving Emergency Department Flow by Using a Provider in Triage Literature Review Chapter

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Emergency Room Efficiency

Improving Emergency Department Flow by Using a Provider in Triage

Emergency room triage plays an essential role in the speed and quality of the emergency room departments. Triage represents only one small part of the process that determines quality of patient care. Emergency rooms can be crowded. Busy times are often unpredictable, making it difficult to avoid bottlenecks in the system. This has an affect on the amount of time between arrival and when the patient sees a physician. Patients can be in for frustrating long waits while sitting in the hospital lobby.Patients often leave the emergency room waiting areas without being seen because they get tired of waiting. These patients are referred to as left-without-being seen (LWBS). Reducing LWBS rates is crucial for improving quality of patient care in emergency rooms. Long waits also cause a potential liability for the hospitals, as patients that are critically ill may not be seen or assessed in time. Not only must the speed of triage be improved, but the accuracy as well. Accuracy is essential in the maintenance of quality patient care from the time of arrival until the patient leaves the facility.

This literature review will explore research on reducing emergency triage wait times and improving quality by including a Physician as part of the triage team. Vast research effort has been devoted to reducing emergency department wait times and improving quality. Numerous methods for reducing wait times have been explored as well. One of the most widely researched methods involved whether having a physician in the triage area reduced wait times and resulted in improved patient quality of care. The following explores these literature review results.

Although the topic of an emergency room wait times and quality has appeared in many mass media and professional publications, only credible academic research studies will be considered in conducting this literature review. Reducing emergency room wait times and quality of care, with a focus on the triage area has been a topic of research globally, as well as in the United States. Many relevant studies were found that were conducted outside of the United States. Only those that were relevant to the specific topic area and to hospital operations in the U.S. were considered. Several studies of international origin were included, as they significantly added to the ability to identify gaps and needs within the research parameters of this study.

The Issue of Emergency Room Crowding and Speed

Reducing emergency room wait times is an important topic for many reasons. McHugh and Van Dyke (2011) explored the need to reduce emergency department crowding and strategies to achieve this goal. The key findings were that reducing emergency department crowding reduces the quality of care. Secondly, it is costly and compromises community trust. The key to reducing emergency room crowding is to improve the patient flow throughout the emergency department and the rest of the hospital.

According to McHugh and Van Dyke, one of the key suggestions for improving patient flow is to develop a patient flow improvement team. Members of the team should include physicians, nurses, and support staff. It was further found that consideration of both team and hospital goals, as well as available resources were a key to the development of strategies for improving emergency department patient flow. Improving emergency department patient flow will involve many changes in procedures. It will require a culture change within the organization. Many staff members may be resistant, which represents one of the key obstacles that the team will face.

Elmqvist, Fridlund & Ekebergh (2012) found that performing lifesaving actions, while at the same time creating good relationships with the patient and next of kin, requires continuous movement between these two functions. Emergency room providers are under considerable stress due to time pressure and must develop different strategies to cope with their work. Redesign of internal work processes can help to reduce the stress experienced by emergency department personnel to help them find a balance between maintaining patient safety and next of kin relationships while performing their duties.

Aekun, Briggs, & Patel et al. (2010) evaluated factors both intrinsic and extrinsic that influenced patient throughput in emergency departments. The study used an observational design to determine the list of variables that played a role in patient wait times in the emergency department. Observations took place at 8:00 PM Monday through Friday during a three-month period. This method reduced the effect of busy and slow times at the hospital. Weekends are typically busier than weekdays and emergency departments.

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This method added consistency to the study method. Daily volume in the emergency room, patient acuity, staffing levels, occupancy, daily admissions, hospital volume, and intensive care unit volume were all taken into consideration in the analysis.

The study treated patients as samples for the purpose of the study. During the observation period the emergency department capacity averaged 85%. The door to physician time was 1.8 hours, with the biggest influence being the triage department. The day of the week and emergency department occupancy were found to play significant roles in the amount of time spent in the triage department. The triage department was cited in many studies as being the department most responsible for decreased patient flow times.

Types of triage and Effectiveness

Shea & Hoyt (2012) found that the traditional nurse triage model creates barriers in the process of rapidly evaluating patients when they first arrive at the emergency room. Strategies must be explored to improve time of arrival to the time they see a provider and undergo the screening process. The RAPID team triage system represents a change in the way triage is handled in the emergency room. The focus of this system switches from a hospital/system centered approach to a patient-centered approach.

Farroknia, Castron, & Elurenberg et al. (2011) performed a systematic review of studies on triage scales used by emergency departments. The ability of different scales to predict patient outcomes is a topic seldom addressed in academic research. However, this factor will play a key role in the ability to isolate the effects of the Physician in the emergency room from any effects that are caused by the various triage scales used by different emergency departments. The effect of various scales on triage in emergency department efficiency represents an external variable in this research study.

The ability to reproduce reliable results using the various scales is difficult to measure due to differences in patient circumstance and provider interpretation. The scales assessed in the study were the GRADE, CTAS, ATS, and METTS scales. It was found that information needed to assess the effectiveness of the scale in reducing death or hospitalization of patients assigned to the lowest two triage levels on five-level scales was inadequate to draw conclusions. The study utilized an examination of other studies regarding those various scales. The study showed that the risk of death was low for the lower triage categories, but the need for inpatient care was excluded from the study.

These study results were disturbing for many reasons. Evidence was insufficient to assess the validity of the scales, but their ability to distinguish the urgency of patients assigned five to different levels, regardless of the scale being used was poor. It was difficult to assess mortality rates among different triage levels, even with the adjustment of age and gender. This is largely because a higher risk of mortality is generally associated with higher triage scale levels, with the highest number on the scale representing the most urgent patients. The major concern of this study was the safety of the scales and their ability to accurately assign categories. Early death among the lower levels of triage patients was used as the study instrument. The ATS and CTAS scales only offered limited evidence in relation to their ability to assess the safety of patients. Patients assigned the lowest level of triage using the scale were found to have a low mortality rate within 24 hours after triage. However, it is not known if these results would change using a different patient population.

Even though evidence was limited, it appears that the scales are safe in respect to their assessment of lower levels of patient categories. Evidence regarding the METTS scale was inconclusive, as this is a newer scale that has recently been developed. At present, the METTS scale has only been employed in Swedish hospitals. It was noted that many external variables exist that could have affected the results of the study. These research studies included overall patient populations in the emergency department, access to hospital beds, the hospital admission policies, and the presence of inaccurate triage decisions. Measurement of the accuracy of the triage decision only considered patients that were assigned a lower category, rather than that which represented their actual urgency for treatment. The same variables will affect the current research study and will have to be addressed in the methodology portion of the study.

Farroknia, Castron, Elurenberg and associates were unable to draw definitive conclusions as….....

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