Does a senior physician at triage improve flow through the Emergency Department?
Date First Published:
March 23, 2015
Last Updated:
March 23, 2015
Report by:
Charlotte Little, Student Doctor (University of Cambridge)
Three-Part Question:
In [a busy adult or mixed (adult and paediatric) Emergency Department], does [having a physician at triage] [improve length of stay (LOS) and flow through department]?
Clinical Scenario:
You are the emergency physician in charge of a busy Emergency Department (ED) in a large hospital. The department is experiencing overcrowding and you are investigating possible solutions. You wonder whether placing a senior physician at triage will help to improve flow through the department and reduce patient length of stay (LOS) and ED crowding.
Search Strategy:
Medline using the following search strategy:
[exp EMERGENCY SERVICE, HOSPITAL/ (MeSH)] AND [exp TRIAGE/ (MeSH) or triag* (free text) OR “rapid assessment”] AND [doctor* OR consultant* OR intern* OR physician* OR registrar (free text)] AND [time* OR timing OR delay* OR wait* (free text)] AND [Limit to: English Language and Publication Year 1966-2015]
Cochrane Library using the following search strategy:
[[MeSH descriptor: [Emergency Service, Hospital] this term only] OR [MeSH descriptor: [Emergency Medical Services] explode all trees]] AND [[MeSH descriptor: [Triage] explode all trees] OR triage or "rapid assessment"] AND [doctor or consultant or intern or physician or registrar] AND [time or timing or delay or wait] AND [Limit to English Language]
[exp EMERGENCY SERVICE, HOSPITAL/ (MeSH)] AND [exp TRIAGE/ (MeSH) or triag* (free text) OR “rapid assessment”] AND [doctor* OR consultant* OR intern* OR physician* OR registrar (free text)] AND [time* OR timing OR delay* OR wait* (free text)] AND [Limit to: English Language and Publication Year 1966-2015]
Cochrane Library using the following search strategy:
[[MeSH descriptor: [Emergency Service, Hospital] this term only] OR [MeSH descriptor: [Emergency Medical Services] explode all trees]] AND [[MeSH descriptor: [Triage] explode all trees] OR triage or "rapid assessment"] AND [doctor or consultant or intern or physician or registrar] AND [time or timing or delay or wait] AND [Limit to English Language]
Outcome:
514 papers were found using the Medline search, of which 498 were irrelevant and 6 were of insufficient quality for inclusion.
55 papers were found using the Cochrane Library search, of which all were either irrelevant or previously found in the Medline search.
10 relevant papers were found using the Medline search and 1 additional study was identified from a systematic review. These are shown in the table below.
55 papers were found using the Cochrane Library search, of which all were either irrelevant or previously found in the Medline search.
10 relevant papers were found using the Medline search and 1 additional study was identified from a systematic review. These are shown in the table below.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| 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) o Cheng I et al 2013 Canada | Non-critically ill ED patients, 8:00-14:30 during 131 weekday shifts across 26 weeks (65 days randomised to intervention and 66 days to control cluster).(n=6,300 pts, 750 seen by doctor). Academic tertiary level hospital. | Cluster randomised controlled trial | #NAME? | -tED LOS decreased by 28min for high acuity patients (4:01hrs v 4:29hrs) (p=0.01) and 58min for low acuity patients (1:10hrs v 2:08hrs) (p<0.001) receiving intervention. | - There was an extra nurse at triage as well as extra EP, which may account for some benefits seen. - Evenings and weekends not studied. - Single-centre trial. |
| #NAME? | #NAME? | ||||
| #NAME? | -tLWBS rate decreased by 0.7% (1.5% v 2.2%). | ||||
| #NAME? | #NAME? | ||||
| Impact of a Triage Liaison Physician on Emergency Department Overcrowding and Throughput: A Randomized Controlled Trial Holroyd BR et al 2007 Canada | All adult ED patients, 11:00-20:00 during 42 days (21 control and 21 intervention shift days). (n=5,718 pts). Academic urban tertiary ED. | Randomised controlled trial | #NAME? | -tED LOS decreased by 36min (4:21hrs v 4:57hrs). | - No power calculation. - Additional member of staff employed for intervention, therefore extra staffing may account for some benefits (rather than specific physician in triage role.) - Single-centre trial. |
| #NAME? | -tLWBS decreased from 6.6% to 5.4% (statistically non-significant). | ||||
| Placing physician orders at triage: the effect on length of stay. Russ S et al. 2009 USA | All adult ED patients. Physician at triage 11:00-23:00, 5-6 days per week. (n= 10,901 matched pairs of pts). Urban academic tertiary care Medical centre. |
Retrospective data collection, comparing patients receiving physician orders at triage with matched control patients not receiving physician orders | #NAME? | -tMedian ED LOS increased by 11min for those receiving triage orders. | - Comparison is between patients who do and don’t receive physician orders at triage, rather than all patients who are assessed by a physician at triage. - No randomisation of patients in intervention/control groups - potential bias. - Single centre study. |
| #NAME? | - Median waiting room time increased by 41min for patients receiving intervention. | ||||
| #NAME? | -tMedian time in ED bed decreased by 37min for patients receiving intervention. | ||||
| Impact of physician screening in the emergency department on patient flow. Soremekun OA et al. 2012 USA | All medium acuity adult ED patients who were subsequently admitted, 11:00-23:00 over 2 year period (12 month pre- and 12 month post-intervention). (n=20,312 pts). Large urban teaching hospital. | Retrospective study - 12 months pre- and post-introduction of physician at triage | #NAME? | -tED LOS decreased by 13 min (p=0.001). | - Retrospective design. - No randomisation. - Increase in admissions by 14% between the two study periods - Used physician order time on computer which was probably later than time seen, possibly underestimating the effect. - Single centre study. |
| #NAME? | -tMedian time to disposition decision decreased by 6min (260min v 254min) (p=0.025). | ||||
| #NAME? | - Median times to physician orders all decreased by 16 - 70 min | ||||
| Does rapid assessment shorten the amount of time patients spend in the emergency department? Jarvis PRE et al. 2014 UK | All ED patients (adult and paediatric) between 09:00-17:00, excluding minor injuries, during control phase (54 days) and intervention phase (19 days). (n=4,622 pts). District general hospital ED (major trauma unit). | Prospective, non-randomized observational study |
-tTime to ‘emergency department ready’ (ED management complete) | -tMedian time to ‘emergency department ready’ reduced significantly by 53mins (129mins v 76mins) (P<0.0001) | - Point of care testing was implemented alongside rapid physician assessment at triage, therefore cannot analyse impact of doctor at triage alone. - Triage consultant was additional member of staff. - Control and intervention phases were during different seasons – other factors may have affected outcome measures. - Single-centre study. |
| #NAME? | -tMedian time to first clinical assessment reduced by 8mins (12mins v 4 mins) (P<0.0001) | ||||
| Physician in triage improves emergency department patient throughput. Imperato J et al. 2012 USA | All ED patients (adult and paediatric), 13:00-21:00 during 6 months (3 month control and 3 month intervention period). (n=17,631 pts). Small community teaching hospital. | Retrospective study – 3 months pre- and post-introduction of physician at triage | #NAME? | -tOverall median ED LOS reduced by 13 min (3:48hrs to 3:35hrs) (p <0.001). This reduction was greater for admitted patients than for discharged ones (24min vs 7min). | - Retrospective study. - PIT (Physician in Triage) only for 8hr per day (13:00-21:00), whilst data from 24hrs included in results. - Average daily volume was higher during the intervention period and also less experienced staff were used during the intervention, both of which may reduce the effect. - Additional doctor used during intervention – results possibly due to increased staffing. - Single centre study. |
| LWBS rate | LWBS rate decreased from 132 to 121 pts (non-significant). | ||||
| The effect of physician triage on emergency department length of stay. Han JH et al. 2010 USA | All ED patients, during 18 week period (9 weeks pre- and 9 weeks post-intervention). Physician triage 13:00-21:00. (n=17,265 pts). Urban academic tertiary care and Level I trauma centre. | Retrospective study - 9 weeks pre- and post- introduction of physician at triage | #NAME? | - Median ED LOS overall decreased by 11min for whole cohort, but no significant difference in ED LOS for admitted patients, due to exit block. | - Retrospective data collection. - Triage physician was additional member of staff therefore extra staffing may account for some benefits seen. - Data collected for patients in 24hr periods whilst intervention for only 8hrs per day –Short study period. - Single-centre study. |
| #NAME? | - LWBS decreased from 4.5% to 2.5%. | ||||
| A Long-term Analysis of Physician Triage Screening in the Emergency Department. Rogg JG et al. 2013 USA | All medium-acuity ED patients (adult and paediatric), during 1 year pre- and 3 years post- introduction of START (Supplemented Triage and Rapid Treatment). (n= 180,871 pts (39,142 pre- and 141,729 post-intervention)). Large, urban, academic tertiary care ED and Level 1 trauma centre. | Large retrospective, observational, before-and-after study | #NAME? | -tMedian ED LOS decreased by 56min for pts eligible for START. | - Retrospective study. - Changes in ED data across study period – eg. annual ED volume increased by 12% from pre- to post-intervention and increase in nurses. - Single-centre study. - No blinding or randomisation. |
| #NAME? | -tED LOS for all pts (including low/high acuity) decreased by 30mins. | ||||
| #NAME? | -tLWBS rate decreased from 4.8% to 2.9%. | ||||
| Does having an emergency physician at triage for a 4-hour shift reduce ED length of stay? [abstract] Gray SH, Kingsley SJ, Spence JM. 2009 Canada | All ED patients, during 4hr afternoon shifts across 6 weeks (3 control and 3 intervention weeks). (n=5,020 pts). Large urban ED. | Clinical controlled trial | #NAME? | -tED LOS did not reduce significantly (396min v 409min) (p=0.32). | - Only had physician in triage for 4hr shifts. - Single centre study. |
| #NAME? | -tLWBS rate decreased from 6.3% to 5.7%. | ||||
| #NAME? | - Mean time to see physician did not reduce (111min v 112min) (p=0.61). | ||||
| Improvement in emergency department length of stay using an early senior medical assessment and streaming model of care: A cohort study. Asha SE and Ajami A. 2013 Australia | Ambulant ED pts age >16yrs who were selected by triage nurse as appropriate for consultant assessment, arriving 12:00-18:00 Fri-Mon across 3 months (intervention group). Control group – all ED pts 12:00-18:00 Tues-Thurs in same 3 months. (n=18,962 pts). ED of tertiary referral centre. | Prospective, non-randomised cohort study | -tProportion of pts meeting 4hr target in different subcategories (per whole day, between 12:00-18:00, in admitted pts, in discharged pts) | -tOdds of pts meeting 4hr target, when controlled for confounding effects, was 15% higher on intervention days (P < 0.001). | - Pts were initially triaged by a nurse, and then those selected were sent to a SAS (Senior Assessment and Streaming) team including consultant, nurse and intern. Therefore results not strictly/only based on physician at triage. - No randomisation, and intervention was carried out on peak days only - Physician at triage was additional staff member - Single-centre study |
| #NAME? | - LWBS rate improved by 0.34% (2.5% v 2.84%) (p=0.17); when controlled for confounding LWBS was 28% lower (P=0.003) | ||||
| Faculty Triage Shortens Emergency Department Length of Stay. Partovi SN et al. 2001 USA | All ED patients (adult and paediatric), 09:00-21:00 on 16 consecutive Mondays (8 intervention and 8 control shifts). (n=1,734 pts). Academic, urban hospital. |
Prospective controlled trial – non- randomised | #NAME? | -tMean ED LOS decreased by 82min (363min v 445min). | - Single-centre trial. - No randomisation or blinding used. - US health system very different to NHS. |
| #NAME? | - LWBS rate decreased by 46% (7.9% v 4.7% patients). |
Author Commentary:
All studies found were single centre trials only. Only two adequately randomised controlled trials were found; both of these showed a reduction in ED LOS but one showed no
difference in LOS for patients being admitted. The other trials often added an extra doctor to the department during their trial period, making it difficult to know if the effect on LOS was due to early senior triage or increased staffing. Whilst most studies report some reduction in flow measures such as LOS and LWBS (left without being seen) rate, the results were variable. There were also many potential problems with bias and confounding due to the retrospective before and after nature of many of the studies. In systems with significant exit block due to inpatient bed shortages, physician triage is expected to improve safety and quality by treating and investigating patients earlier but it may not consistently reduce LOS.
difference in LOS for patients being admitted. The other trials often added an extra doctor to the department during their trial period, making it difficult to know if the effect on LOS was due to early senior triage or increased staffing. Whilst most studies report some reduction in flow measures such as LOS and LWBS (left without being seen) rate, the results were variable. There were also many potential problems with bias and confounding due to the retrospective before and after nature of many of the studies. In systems with significant exit block due to inpatient bed shortages, physician triage is expected to improve safety and quality by treating and investigating patients earlier but it may not consistently reduce LOS.
Bottom Line:
Having a physician at triage may improve flow, LOS and other safety and quality measures, but further good evidence in the form of randomised controlled trials are needed to see if this is a consistent outcome.
References:
- Cheng I et al. 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) o
- Holroyd BR et al. Impact of a Triage Liaison Physician on Emergency Department Overcrowding and Throughput: A Randomized Controlled Trial
- Russ S et al.. Placing physician orders at triage: the effect on length of stay.
- Soremekun OA et al.. Impact of physician screening in the emergency department on patient flow.
- Jarvis PRE et al. . Does rapid assessment shorten the amount of time patients spend in the emergency department?
- Imperato J et al. . Physician in triage improves emergency department patient throughput.
- Han JH et al. . The effect of physician triage on emergency department length of stay.
- Rogg JG et al. . A Long-term Analysis of Physician Triage Screening in the Emergency Department.
- Gray SH, Kingsley SJ, Spence JM. . Does having an emergency physician at triage for a 4-hour shift reduce ED length of stay? [abstract]
- Asha SE and Ajami A.. Improvement in emergency department length of stay using an early senior medical assessment and streaming model of care: A cohort study.
- Partovi SN et al. . Faculty Triage Shortens Emergency Department Length of Stay.