Day 2 Physician Triage
Impact of an Emergency Physician at Triage
A Pilot Project
W. Sabados, P. McElheran, M. Cloutier, A. Grunfeld BACKGROUND
Emergency department crowding recognized to be a major, international concern that affects patients and providers
Institute of Medicine: recent report noted that the increasing strain caused by crowding is creating a deficit in quality of emergency care. BACKGROUND Crowding associated with: Reduced access to emergency medical services Delays in care for cardiac patients Increased patient mortality Extended patient transport time Inadequate pain management Violence of angry patients against staff Increased costs of patient care Decreased physician job satisfaction BACKGROUND Investigators have proposed a variety of approaches to crowding When no ED beds available: Physician at triage Alone or as part of a multidisciplinary team Studies of EDs in the UK, Australia, Singapore, Hong Kong and the US showed that such interventions significantly decreased patients leaving without being seen, average wait times and length of stay. BACKGROUND
May 2006 – Media attention to congestion in EDs BC Ministry of Health responded with allocation of “one time” funding to Fraser Health for 2006/07 Each site was required to consult with front line staff and BCNU in order to determine key priorities for the funding FH submitted the priorities to the Ministry for approval BACKGROUND SMH submitted a Trial of a Rapid Assessment Zone - not approved Approved list for SMH: Increasing weekend porter coverage Increasing care aides Upgrading the ED security system Updating patient education materials Improving patient flow for CTAS 3. Efforts to improve patient flow were not successful & funding remained available in the last quarter of the fiscal year In January 2007, following a site visit to University of Edmonton ED, it was decided to initiate the Physician at Triage trial Hypothesis : Having an emergency physician working at Triage would decrease patients’ length of stay in the department. Methods
Intervention :
Placing an emergency physician at Triage each day from 1200-2000 hours on alternating weeks for an eight week period.
The physician assessed and initiated investigations and treatment on CTAS 3 patients while they were in the waiting room (CTAS 1 and 2 patients were seen in the Acute Care area and CTAS 4 and 5 patients were triaged to the Minor Treatment Unit) Methods
Outcomes measured :
Time from triage to emergency physician ( not the physician at triage) Time from triage to discharge Percentage of patients discharged in less than 3 hours and 5 hours Number of patients leaving without being seen Ambulance wait times
Data prepared and analyzed by: Decision Support Services - May 2007 Total ER Outpatient Visits 8892 Total ER Outpatient Visits - Excludes LWBS 8355 Triage Date/Time Blank 14 Doc Seen Date Incorrect 262 Doc Seen Date Blank 304 Doc Seen Time Incorrect/Blank 830 Triage to Doc Seen (< 0, > 24 hrs) 1016 Total Valid Cases 7293 Total Invalid Cases (#) 1062 Total Invalid Cases (%) 12.7% Time from Triage to Emergency Physician - All ER Visits Time from Triage to Emergency Physician - Outpatients Only Time from Triage to Discharge - Outpatients Only Time from Triage to Emergency Physician Outpatient visits
Mean Median (range) (range)
Control Weeks - 1, 3, 5, 7 1.9 (1.7-2) 1.5 (1.3-1.6)
MD at Triage Weeks - 2, 4, 6, 8 1.5 (1.3-1.6) 1.1 (0.9-1.3)
Mean time decreased by 22% (p=0.003) LENGTH OF STAY
Time Period Maen LOS Median LOS (range) (range)
Fiscal 2005/06 2.9 2.3 Fiscal 2006/07 Pd 1-12 2.9 2.4 Control Weeks - 1, 3, 5, 7 2.9 (2.7 - 3.1) 2.4 (2.2 - 2.6) MD at Triage Weeks - 2, 4, 6, 8 2.4 (2.4 - 2.8) 2.0 (2.0 - 2.4)
Mean LOS decreased by 13%(p=0.02) Effect on Discharges within 3 and 5 hours
% < 3 hrs % < 5 hrs
Control Weeks - 1, 3, 5, 7 63.9 (61.3 - 68.5) 86 (84.5 - 88.2)
MD at Triage Weeks - 2, 4, 6, 8 69.9 (64.9 -74.2) 91.4 (89.3 - 94.2) BC Ambulance Service Delay Times
Mean Range Control Weeks - 1, 3, 5, 7 15.1 hrs 13.8 - 16.8 hrs MD at Triage Weeks - 2, 4, 6, 8 12.3 hrs 10.2 - 14.3 hrs
Mean service delay improved by 2 h 53 min - 19% decrease(p=0.04) Left Without Being Seen Time Period Mean Range
Fiscal 2005/06 7.1% 5.4% - 9.2% Fiscal 2006/07 Pd 1-12 5.7% 4.9% - 6.5% Control Weeks - 1, 3, 5, 7 5.95% 3.9% - 8.1% MD at Triage Weeks - 2, 4, 6, 8 4.35% 3.2% - 5.2%
Percentage LWBS dropped by an average of 27% (p=0.17) Projected Emergency Department Length of Stay With Full Coverage
Total patient visits - Fiscal Year 2006/07 67,875 Between 1200-2000 hrs: 29,865 patient visits 44.0% of cases registered Physician at triage for 24/7: Estimated average time save of 40.9 minutes per case CONCLUSIONS Physician present at Triage for an 8 hour period resulted in substantial improvement over the entire 24 hours:
Decrease in overall wait time to see the treating physician Decrease in overall turn around time – triage to discharge Increase in the percentage of patients discharged within 3 hours and 5 hours Improvement in BC Ambulance Service daily delay times Reduction in the number of patients LWBS CONCLUSIONS
An improvement in patient wait times, turn- around time and better flow through the Emergency Department
Potentially increased patient satisfaction