Original Research
Team Assignment System: Expediting Emergency Department Care

https://doi.org/10.1016/j.annemergmed.2005.06.012Get rights and content

Study objective

We designed and implemented an emergency department (ED) team assignment system, each team consisting of 1 emergency physician, 2 nurses, and usually 1 technician. Patients were assigned in rotation upon arrival to a specific team that was responsible for their care. We monitored the time from arrival to physician assessment, percentage of patients who left without being seen by a physician, and patient satisfaction before and after team assignment system implementation.

Methods

This study was done in a suburban community hospital with an annual ED census of approximately 39,000. Time to physician assessment was defined from the completion of the medical screening evaluation by an ED nurse at triage to initiation of emergency physician evaluation. Times were documented on the ED paper record and manually entered into a computerized registration by the clerical staff. Patients who left without being seen was reported as percentage of total ED visits. Patient satisfaction scores using a 5-point Likert scale to assess satisfaction with the emergency physician, ED staff courtesy, and coordination of care were gathered every 3 months from random mailings to a subset of patients.

Results

The 12-month ED census was 38,716 before team assignment system implementation and 39,301 afterwards. Complete time data were recorded for 34,152 (88.2%) and 32,537 (82.8%) of the patients, respectively. The mean time to physician assessment was 71.3±7.0 minutes before and 61.8±6.4 minutes after team assignment system implementation (absolute difference −9.5 minutes; 95% confidence interval [CI] −5.8 to −13.5 minutes). The percentage of patients seen by a physician within 1 hour was 56.3% before and 64.0% after team assignment system implementation (absolute difference 7.7%; 95% CI 5.1% to 10.3%). The percentage of patients who waited more than 3 hours for physician assessment was 17.8% before and 11.8% after team assignment system implementation (absolute difference −6.0%, 95% CI −4.0% to −8.1%). Before team assignment system, the left without being seen rate was 2.3% compared to 1.6% after team assignment system (absolute difference −0.8%; 95% CI −0.4% to −1.1%). Patient satisfaction reported as very good or excellent showed improvement in satisfaction with the physician (absolute increase 3.1%; 95% CI 1.0% to 5.3%), staff courtesy (absolute increase 4.5%; 95% CI 2.3% to 6.7%), and coordination of care (absolute increase 3.6%; 95% CI 0.8% to 6.4%).

Conclusion

The implementation of a team assignment system in our ED was associated with reduced time to physician assessment, a reduced percentage of patients who left without being seen, and improved patient satisfaction.

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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      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].

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    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.

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