Administration of Emergency Medicine
Impact of Physician Screening in the Emergency Department on Patient Flow

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Abstract

Background

Physician triage is one of many front-end interventions being implemented to improve emergency department (ED) efficiency.

Study Objective

We aim to determine the impact of this intervention on some key components of ED patient flow, including time to physician evaluation, treatment order entry, diagnostic order entry, and disposition time for admitted patients.

Methods

We conducted a 2-year before–after analysis of a physician triage system at an urban tertiary academic center with 90,000 annual visits. The goal of the physician in triage was to arrange safe disposition of straightforward patients as well as to initiate work-ups. All medium-acuity patients arriving during the hours of the intervention were impacted and thus included in the analysis. Our primary outcome was the time to disposition decision. In addition to before–after analysis, comparison was made with high-acuity patients, a group not impacted by this intervention. Patient flow data were extracted from the ED information system. Outcomes were summarized with medians and interquartiles. Multivariable regression analysis was performed to investigate the intervention effect controlling for potential confounding variables.

Results

The median time to disposition decision decreased by 6 min, and the time to physician evaluation, analgesia, antiemetic, antibiotic, and radiology order decreased by 16, 70, 66, 36, and 16 min, respectively. These findings were all statistically significant. Similar results were observed from the multivariable regression models after controlling for potential confounding factors.

Conclusions

Physician triage led to earlier evaluation, physician orders, and a decrease in the time to disposition decision.

Introduction

Prolonged wait times is an issue faced by many emergency departments (EDs) around the United States, and conflicts with one of the key tenets of emergency medicine: to provide rapid evaluation and treatment for patients with urgent and emergent conditions (1). Recent publications have highlighted that the delay in evaluation and treatment affects patients of all acuity, and although the majority of patients presenting to EDs experience longer waits than is generally accepted, medium-acuity patients are disproportionately impacted 2, 3.

These delays impact the quality of care for patients with serious conditions such as sepsis and myocardial infarction, where prompt evaluation and treatment has been shown to positively impact outcomes 4, 5, 6.

In addition, prolonged wait time also impacts patient satisfaction, with prolonged wait times correlated to lower levels of patient satisfaction and high rates of patients leaving without being seen (LWBS) 7, 8. According to the literature, patients expect to be evaluated by a physician in less than an hour and the disposition decision made in < 3 h 9, 10. Many EDs are unable to meet this expectation, leading to high rates of dissatisfaction with ED care and LWBS.

Physician triage is one of several front-end interventions being implemented in some EDs to decrease time to physician evaluation, diagnostic testing, treatment, and disposition (11). Physician triage is a system where a designated physician is deployed to intervene early in patients’ ED course to guide triage or accelerate the initial evaluation and treatment of patients during a period when patients otherwise would be waiting for a bed space in the ED. While this intervention has been implemented in a non-standardized format across institutions, the majority have demonstrated a positive impact on efficiency, leading to a reduction in key operational performance measures like time to initial physician evaluation, ED length of stay (LOS), and the number of patients who LWBS 12, 13, 14, 15.

Whereas some positive operational improvements associated with physician triage have been described in the literature, the impact on specific components of ED patient flow—time to physician evaluation, diagnostic tests, treatment delivery, and disposition—adjusting for confounding variables such as ED census and triage physician experience level has not been well described in the literature. In this study we aim to describe the impact of physician triage on components of the ED care delivery process and the impact on overall patient flow for patients admitted to the hospital or observation unit.

Section snippets

Methods

The study was a retrospective review 12 months pre- and post-implementation of a physician triage system. The study was performed in an urban tertiary academic center with approximately 90,000 annual visits and an overall admission rate of approximately 27%. The center has four adult treatment areas: one high-acuity area, two medium-acuity areas, and one fast-track area. There are also separate dedicated pediatric and acute psychiatric treatment areas. Besides a 4.5% growth in total ED visits

Results

The total number of admitted medium-acuity patients arriving to the ED during the hours of 11:00 a.m.–11:00 p.m. was 20,318 during the 2-year period (9506 pre-implementation and 10,812 post-implementation). The characteristics of admitted patients triaged to the medium-acuity areas pre- and post-implementation of the intervention can be seen in Table 1. Besides a 14% growth in volume of admitted medium-acuity patients and a 4% growth in the overall mean ED census at time of patient arrival in

Discussion

Physician triage is one of the many front-end interventions being implemented to improve ED efficiency and tackle the prolonged wait times for evaluation and treatment (11). Although the majority of institutions implementing this intervention have observed reductions in LWBS and ED LOS, Russ et al. actually noted an increase in ED LOS after implementation of physician in triage (12, 13, 14, 15, 16).

In our study, we looked at the impact of physician triage on the components of flow and the

Conclusion

Physician triage that focuses on both the disposition of straightforward patients and initiating work-ups, leads to a modest improvement in the time to disposition decision for admitted patients and more marked improvements in the times to evaluation, diagnostic testing, and initiation of critical treatments. These improvements are in line with the key tenets of emergency medicine and patient expectations.

Article Summary

1. Why is this topic important?

  1. Placing a physician in triage is one of several front-end interventions that have been

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