Original ResearchTeam Assignment System: Expediting Emergency Department Care
Introduction
Emergency department (ED) crowding is a serious, growing problem.1, 2, 3 Causes of ED crowding include high acuity,1, 4, 5, 6, 7, 8, 9 hospital inpatient bed shortages and boarding of admitted patients in the ED,1, 3, 4, 6, 8, 9, 10, 11, 12 radiograph and laboratory delays,4, 6, 7, 8 inadequate physical ED space,4, 6, 8 increased ED demand,4, 5, 6, 11, 12 inadequate funding for emergency health care,10 and long waiting times.13 In a conceptual model, ED crowding results when inflow is greater than outflow.2, 14
The net effects of ED crowding include poor patient outcomes,4, 6, 7, 12 long waits to be seen,6, 7 patient dissatisfaction and patient complaints,3, 6, 15 ambulance diversion,6, 12, 14, 16 and increased number of patients who leave without being seen.12, 14, 17 Delayed therapy for patients who have acute myocardial infarction, cerebrovascular accident, sepsis, intracranial hemorrhage, and incarcerated hernias can result in poor outcomes and death as a direct result of ED crowding.4, 6, 18
Most of the factors that contribute to ED crowding (ED census, consultant wait times, laboratory and radiograph turnaround times, and admission wait times) are beyond the direct control of the ED (physicians, nurses, and administration). However, ED crowding may be affected by reducing waiting times for the placement of patients in ED beds to initiate earlier patient care and by getting prompt discharge dispositions so the ED bed can be available for the next patient.15 In many EDs, newly registered walk-in patients are placed in a queue of ready-to-be-seen cases, which allows physicians to “sign up” for patients when they feel ready to see their next patient. Physicians perceive their patient loads differently and “sign up” for additional patients at varying rates.19 These rates are related to varying factors including each individual physician's tolerance of workloads, personal work ethic, departmental and management expectations, and monetary remunerations. Additionally, waiting patients often remain no one's direct responsibility until an available physician takes ownership of that next case,19, 20 resulting in delays in care.
The lack of responsibility for ready-to-be-seen but unassigned patients may contribute to prolonged waiting times.19, 20 Patient satisfaction often declines when waiting times increase and ED crowding occurs.19, 20, 21, 22, 23 To decrease wait times in our ED, we designed and implemented a team assignment system in which patients are assigned to a team consisting of 1 physician, 2 nurses, and usually 1 ED technician after a nurse completes the medical screening examination. Our primary goal was to decrease the time from medical screening examination completion to physician evaluation as measured by the wait time to be seen by the ED physician, the percentage of patients seen within 1 hour, and the percentage of patients waiting more than 3 hours to be seen by the ED physician. Our secondary goals were to decrease the percentage of patients who left without being seen and improve patient satisfaction.
Section snippets
Theoretical Model of the Problem
This is a before-after comparative study of the effects of team assignment system on predefined outcome measures spanning 1 year on either side of the date of implementation (October 2002). The study period ran from October 1, 2001, through September 30, 2003. The study was approved by the Kaiser Foundation Research institutional review board.
Setting and Selection of Participants
Our ED had a mean annual census of 39,009 patient visits during the study period and was staffed by salaried, board-prepared, or board-certified emergency
Characteristics of Study Subjects
In the 12 months before team assignment system implementation, the ED census was 38,716 compared with 39,301 for the 12 months after team assignment system implementation (Figure 1). Because of incomplete clerical data entry, complete time data were available for 34,152 (88.2%) of the preteam assignment system patients compared with 32,537 (82.8%) of the postteam assignment system patients. The admission rate into the hospital from the ED was 17% in 1999, 17.8% in 2000, 19.4% in 2001, 20.4% in
Limitations
This was an observational study, and, although no other systematic changes in the ED delivery of care were undertaken at this facility during the study period, other unidentified factors may have contributed to the improvement in patient waiting times, left without being seen rates, and patient satisfaction. We used the standard patient satisfaction survey process that all Kaiser Permanente EDs in northern California use. This survey was not specifically designed to assess the impact of a team
Discussion
Our study found that a team assignment system was associated with reduced patient waiting times, reduced leaving without being seen, and improved patient satisfaction. These improvements occurred at the same time our ED census increased by 1.5%. Team assignment system may serve as a useful model that many EDs can implement to improve patient care and ED throughput.
Getting patients in rooms is one of the most significant delays in the ED, and initiating earlier physician evaluation can expedite
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2020, American Journal of Emergency MedicineCitation Excerpt :Previous studies have identified length of wait, updates on expected wait time, triaged priority level, time of day, and month of year [2-6] as important factors which increase likelihood of LWBS and impact time to abandonment. The most commonly identified reason for leaving was the length of waiting time, and many studies have focused on identifying and implementing interventions to cut down on wait times in an attempt to reduce LWBS rates, with some success [6-11]. However, accurately quantifying exact ED abandonment times has historically been challenging, with up to 31% of calculated LWBS waiting times deemed to be inaccurate [12].
Supervising editor: J. Stephan Stapczynski, MD
Author contributions: PBP and DRV conceived the study, designed the trial, and obtained institutional review board approval. PBP obtained the data. PBP and DRV analyzed the data, with assistance from a statistical consultant from Division of Research, Kaiser Permanente. PBP and DRV drafted the manuscript, and each contributed substantially to its final result. PBP created figures, with review by DRV. PBP and DRV take responsibility for the paper as a whole.
Funding and support: The authors report this study did not receive any outside funding or support.
Presented in part at the American College of Emergency Physicians Research Forum, October 2004, San Francisco, CA.
Reprints not available from the authors.