Impact of triage liaison provider on emergency department throughput: A systematic review and meta-analysis

"A banana in the tailpipe": a qualitative study of patient flow in the healthcare system

BACKGROUND

Suboptimal patient flow and impaired hospital access can lead to adverse outcomes, including lower care quality, higher mortality risk, and patient dissatisfaction. Despite awareness, optimizing patient flow remains an area requiring further development. This study aimed to comprehensively identify factors hindering patient flow in a large healthcare system and explore potential solutions, using a qualitative approach for context-specific insights.

METHODS

This qualitative study followed COREQ guidelines. We conducted four focus group discussions (FGDs) involving 23 healthcare workers (HCWs) and patients selected through purposive sampling. The data were analysed using the directed content analysis method, ensuring rigor through methods such as credibility, dependability, authenticity, and transferability. The study also mapped qualitative findings to outcomes from our recent umbrella review (UR) to enhance comprehensiveness.

RESULTS

Patient flow challenges were categorized into population (patients and providers), capacity, and process. Population challenges included community-based care, staffing issues, and inequities in access. The capacity challenges involved inefficient resource allocation, resource constraints, and patient volume growth. The process challenges included bed management, modernization struggles, private hospital issues, funding model problems, information sharing gaps, coordination challenges, transition issues, particularly delayed discharges from inpatient wards, and problems in healthcare management and patient communication. The solutions focused on human factors, infrastructure, and management, organization, and policy. FGDs identified new challenges and solutions were not covered in the recent UR.

DISCUSSION

The participants' insights highlight the critical necessity for systemic improvements, which include enhancing infrastructure, communication, and collaboration. These improvements include early identification of discharge barriers, facilitating community discharge, addressing diverse patient needs, optimizing prehospital services, and improving patient communication. Shifting the focus from traditional emergency department processes to a system-wide approach is crucial. The comparative mapping between FGDs and the UR insights into both common and specific challenges and solutions enriches discussions on healthcare reform.

A National Survey of Caregiver Needs and Experiences When Attending the Emergency Department

OBJECTIVES

Despite being a frequent entry point of care, it remains unknown if families' needs are being met across pediatric emergency departments (PEDs). Study objectives were to describe caregivers' perceived overall PED experience and needs and to what extent these needs were met.

METHODS

This descriptive, cross-sectional survey with medical record review was conducted in 10 Canadian PEDs. Caregivers completed electronic surveys in the PED and within 7 days postvisit. The primary outcome was the degree to which caregivers' overall needs were met in the PED.

RESULTS

A total of 2005 caregivers participated; mean age was 37.8 (standard deviation 7.7) years and 74.3% (1462/1969) were mothers. Mean child age was 5.9 (standard deviation 5.1) years; 51.9% (1040/2003) were male. The median [interquartile range (IQR)] length of stay was 3.9 (2.6-6.1) hours. A total of 22.1% (322/1454) of caregivers reported that their overall needs were not adequately met (Likert scale 1-3/5). The top unmet needs during a PED visit were prompt medical care [20.3% (194/955)], access to practical items [16.8% (160/955)], and effective communication surrounding care [8.7% (83/955)]. Caregiver needs being met were associated with their child's needs being met [odds ratio (OR) 21.2 (13.1-34.2)], child's pain being well managed [OR 3.7 (2.4-5.6)], and satisfaction with overall length of stay [OR 2.6 (1.8-3.8)].

CONCLUSIONS

Almost one fourth of caregivers report their overall needs were not fully met. Improving the quality of PED experience through better communication (ie, wait time delays, medical updates) and earlier pain care initiation may improve family experiences while policymakers work nationally to address lengthy wait times.

Reduced left-without-being-seen rates and impact on disparities after guest services ambassadors implementation

BACKGROUND

The rate of patients who leave without being seen (LWBS) from an emergency department (ED) is a common measurement of quality, operational efficiency, and patient satisfaction. We hypothesized that adding a nonclinical staff role, guest service ambassadors (GSA), to the ED waiting room would decrease LWBS rates and reduce existing differences by race, ethnicity, sex, and primary language for ED patients.

METHODS

We conducted an observational cohort study at a quaternary care academic ED in the Midwestern United States with approximately 60,000 annual visits between April and December 2022. GSAs were trained to guide patients and visitors through the check-in process and help manage the waiting room. LWBS rates were compared between pre- and postimplementation periods using logistic regression. Using two-sample proportion tests, subgroup analyses were performed to assess differences according to race, ethnicity, sex, and primary language.

RESULTS

We analyzed 50,507 ED visits including 9798 during periods of GSA coverage. GSA presence was associated with a reduction in LWBS rate from 3.4% to 2.0% (absolute risk reduction [ARR] of 1.4%, χ2 = 17.357, p < 0.001) with an adjusted odds ratio (OR) of 0.65 (95% confidence interval [CI] 0.49-0.85). There was a greater reduction in LWBS for Black, Indigenous, and people of color (BIPOC) patients compared to White patients (BIPOC ARR 1.8%, 95% CI 0.39%-3.14%; White ARR 1.2%, 95% CI 0.48%-1.94%). There was a reduction in LBWS rates for both males and females (female ARR 1.7%, 95% CI 0.80%-2.63%; male ARR 1.0%, 95% CI 0.06%-1.90%). The reduction in LWBS for patients speaking a language other than English and requiring interpreter services did not meet statistical significance (ARR 1.4%, 95% CI -1.04% to 3.85%).

CONCLUSIONS

Although some disparities remain, our study suggests that GSAs may provide an effective strategy to reduce the overall LWBS rate and reduce disparities across diverse demographic groups including BIPOC and female patients.

Effective strategies for reducing patient length of stay in the emergency department: a systematic review and meta-analysis

BACKGROUND

Overcrowding is a common issue in emergency departments worldwide. One condition associated with overcrowding is the Emergency Department Length of Stay(EDLOS). Prolonged EDLOS is linked to increased hospitalization costs, worsening clinical outcomes, and deterioration in patient-reported outcomes. Consequently, there is a need to reduce EDLOS, and the scientific literature reports multiple strategies aimed at this goal. Therefore, the objective of this study was to determine strategies statistically significant in reducing the EDLOS.

METHOD

A systematic search was conducted in PubMed, Scopus, the Latin American and Caribbean Health Sciences Literature (LILACS) database, and Google Scholar from January 2000 to January 2024. Studies that included patient care strategies in emergency departments to reduce EDLOS, in adults or pediatric populations, and observational or experimental studies were included. The quality of the studies was assessed using the Cochrane Collaboration's Risk of Bias tool for Interventional Studies, and the certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation criteria. A mean difference analysis in minutes was performed using a random-effects model.

RESULTS

A total of 3410 studies were identified using the search strategy with a total of 245,404 patients were analyzed. Three types of strategies were identified with results in reducing EDLOS. Interventions performed by physicians in the triage area (liaison, supervision, and advanced triage) showed a significant reduction of -21.87 min (95% CI -28.35; -15.38). The second intervention was the use of Point-of-Care Testing, which showed a reduction of -41.98 min (95% CI -98.13; 14.15). The third intervention was the creation of fast-track strategies, which documented a reduction of -21.81 min (95% CI -41.79; -1.83). Most of the studies were of the before-and-after type. The certainty of the evidence for the first intervention was moderate, while for the other two groups, it was considered low.

CONCLUSION

The presence of a physician in the triage team demonstrated a reduction in patient EDLOS, although with high heterogeneity among the analyzed studies. Similarly, the use of fast-track strategies is also significantly useful in reducing EDLOS, while POCT reduces EDLOS but not significantly.

Interventions to improve emergency department throughput and care delivery indicators: A systematic review and meta-analysis

BACKGROUND

Emergency department (ED) crowding has repercussions on acute care, contributing to prolonged wait times, length of stay, and left without being seen (LWBS). These indicators are regarded as systemic shortcomings, reflecting a failure to provide equitable and accessible acute care. The objective was to evaluate the effectiveness of interventions aimed at improving ED care delivery indicators.

METHODS

This was a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing ED interventions aimed at reducing key metrics of time to provider (TTP), time to disposition (TTD), and LWBS. We excluded disease-specific trials (e.g., stroke). We used Cochrane's revised tool to assess the risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations to rate the quality of evidence. The meta-analysis was performed using a random-effects model and Cochrane Q test for heterogeneity. Data were summarized as means (±SD) for continuous variables and risk ratios (RR) with 95% confidence intervals (CIs).

RESULTS

We searched MEDLINE, EMBASE, and other major databases. A total of 1850 references were scanned and 20 RCTs were selected for inclusion. The trials reported at least one of the three outcomes of TTD, TTP, or LWBS. Most interventions focused on triage liaison physician and point-of-care (POC) testing. Others included upfront expedited workup (ordering tests before full evaluation by a provider), scribes, triage kiosks, and sending notifications to consultants or residents. POC testing decreased TTD by an average of 5-96 min (high heterogeneity) but slightly increased TTP by a mean difference of 2 min (95% CI 0.6-4 min). Utilizing a triage liaison physician reduced TTD by 28 min (95% CI 19-37 min; moderate-quality evidence) and was more effective in reducing LWBS than routine triage (RR 0.76, 95% CI 0.66-0.88; moderate quality).

CONCLUSIONS

Operational strategies such as POC testing and triage liaison physicians could mitigate the impact of ED crowding and appear to be effective. The current evidence supports these strategies when tailored to the appropriate practice environment.

Patient experience of emergency department triage: An integrative review

BACKGROUND

Emergency department (ED) triage is often patients' first contact with a health service and a critical point for patient experience. This review aimed to understand patient experience of ED triage and the waiting room.

METHODS

A systematic six-stage approach guided the integrative review. Medline, CINAHL, EmCare, Scopus, ProQuest, Cochrane Library, and JBI database were systematically searched for primary research published between 2000-2022 that reported patient experience of ED triage and/or waiting room. Quality was assessed using established critical appraisal tools. Data were analysed for descriptive statistics and themes using the constant comparison method.

RESULTS

Twenty-nine articles were included. Studies were mostly observational (n = 17), conducted at a single site (n = 23), and involved low-moderate acuity patients (n = 13). Nine interventions were identified. Five themes emerged: 'the who, what and how of triage', 'the patient as a person', 'to know or not to know', 'the waiting game', and 'to leave or not to leave'.

CONCLUSION

Wait times, initiation of assessment and treatment, information provision and interactions with triage staff appeared to have the most impact on patient experience, though patients' desires for each varied. A person-centred approach to triage is recommended.

Patient flow in emergency departments: a comprehensive umbrella review of solutions and challenges across the health system

BACKGROUND

Globally, emergency departments (EDs) are overcrowded and unable to meet an ever-increasing demand for care. The aim of this study is to comprehensively review and synthesise literature on potential solutions and challenges throughout the entire health system, focusing on ED patient flow.

METHODS

An umbrella review was conducted to comprehensively summarise and synthesise the available evidence from multiple research syntheses. A comprehensive search strategy was employed in four databases alongside government or organisational websites in March 2023. Gray literature and reports were also searched. Quality was assessed using the JBI critical appraisal checklist for systematic reviews and research syntheses. We summarised and classified findings using qualitative synthesis, the Population-Capacity-Process (PCP) model, and the input/throughput/output (I/T/O) model of ED patient flow and synthesised intervention outcomes based on the Quadruple Aim framework.

RESULTS

The search strategy yielded 1263 articles, of which 39 were included in the umbrella review. Patient flow interventions were categorised into human factors, management-organisation interventions, and infrastructure and mapped to the relevant component of the patient journey from pre-ED to post-ED interventions. Most interventions had mixed or quadruple nonsignificant outcomes. The majority of interventions for enhancing ED patient flow were primarily related to the 'within-ED' phase of the patient journey. Fewer interventions were identified for the 'post-ED' phase (acute inpatient transfer, subacute inpatient transfer, hospital at home, discharge home, or residential care) and the 'pre-ED' phase. The intervention outcomes were aligned with the aim (QAIM), which aims to improve patient care experience, enhance population health, optimise efficiency, and enhance staff satisfaction.

CONCLUSIONS

This study found that there was a wide range of interventions used to address patient flow, but the effectiveness of these interventions varied, and most interventions were focused on the ED. Interventions for the remainder of the patient journey were largely neglected. The metrics reported were mainly focused on efficiency measures rather than addressing all quadrants of the quadruple aim. Further research is needed to investigate and enhance the effectiveness of interventions outside the ED in improving ED patient flow. It is essential to develop interventions that relate to all three phases of patient flow: pre-ED, within-ED, and post-ED.

The multicenter impacts of an emergency physician lead on departmental flow and provider experiences

INTRODUCTION

Emergency department (ED) flow impacts patient safety, quality of care and ED provider satisfaction. Throughput interventions have been shown to improve flow, yet few studies have reported the impact of ED physician leadership roles on patient flow and provider experiences. The study objective was to evaluate the impacts of the emergency physician lead role on ED flow metrics and provider experiences.

METHODS

Quantitative data about patient flow metrics were collected from ED information systems in two tertiary hospital EDs and analyzed to compare ED length of stay, EMS hallway length of stay, physician initial assessment time, 72-h readmission and left without being seen rates three months before and following emergency physician lead role implementation. ED flow metrics for adult patients at each site were analyzed independently using descriptive and inferential statistics, t tests and multivariable regression analysis. Qualitative data were collected via surveys from ED providers (physicians, nurses, and EMS) about their experiences working with the emergency physician leads and analyzed for themes about emergency physician leads impact.

RESULTS

The number of ED visits was relatively stable pre-post at the Peter Lougheed Centre (Lougheed) but increased pre-post at the Foothills Medical Centre (Foothills). Post-intervention at Lougheed median ED length of stay decreased by 18 min (p < 0.001) and at Foothills ED length of stay increased by 8 min (p < 0.001). EMS length of stay at Lougheed decreased by 20 min (p < 0.001), and at Foothills length of stay increased by 17 min (p < 0.001). Themes in provider feedback were that emergency physician leads (1) facilitated patient flow, (2) impacted provider workload, and (3) supported patient flow and safety with early assessments, treatments and investigations.

CONCLUSION

In this study, the emergency physician lead impacted ED flow metrics variably at different sites, but important learnings from provider experiences can guide future emergency physician lead implementation.

Realist inquiry: a new way to think about overcrowding interventions

OBJECTIVES

Physician-focused throughput initiatives are intended to mitigate the effects of emergency department (ED) overcrowding. Our tertiary care academic hospital recently piloted an emergency physician leader role intended to improve throughput. Although a separate experimental evaluation of this initiative was undertaken, it was expected that such an evaluation could not alone provide the necessary information to inform 'how' the emergency physician leader intervention worked. The objective of this study was to conduct a realist evaluation of the emergency physician leader. Realist inquiry utilizes Context Mechanism Outcome configurations to determine the impacts of interventions that are often missed by quantitative analysis. Using a realist perspective, this study aimed to evaluate the emergency physician leader initiative's effects on throughput with the goal of building transferable lessons to the implementation of future interventions.

METHODS

Semi-structured interviews with key stakeholders in the intervention were conducted and analyzed using thematic and template techniques specifically aimed at identifying Context Mechanism Outcomes.

RESULTS

13 interviews were conducted with physicians and nurses who identified contexts and mechanisms which promoted or impeded ED throughput. For example, in situations where there was a clear indication for imaging or management that could not be initiated within the scope of a nursing protocol, the emergency physician leader initiating these orders was felt to promote ED throughput. Conversely, in contexts where there was no nurse available to fulfill early orders, the emergency physician leader's initiation of orders was perceived to impede throughput.

CONCLUSION

This evaluation provides insights into the reasoning and behaviour of individuals involved in the emergency physician leader initiative and provides a systematic approach to unraveling its complex causal pathway. Knowledge of context-mechanism-outcome relationships may help implementers design and measure the impact of future physician-focused throughput interventions.

Patient Throughput Initiatives in Ambulatory Care Organizations during the COVID-19 Pandemic: A Systematic Review

BACKGROUND AND OBJECTIVES

Ambulatory (outpatient) health care organizations continue to respond to the COVID-19 global pandemic using an array of initiatives to provide a continuity of care for both COVID-19 and non-COVID-19 patients. The purpose of this study is to systematically identify the facilitators and barriers experienced by outpatient health care organizations in an effort to maintain effective and efficient patient throughput during the pandemic.

MATERIALS AND METHODS

This study systematically reviewed articles focused on initiatives taken by ambulatory care organizations to maintain optimal outpatient throughput levels while balancing pandemic precautions, published during 2020.

RESULTS

Among the 30 articles that met the inclusion criteria, three initiatives healthcare organizations have taken to maintain throughput were identified: the use (and enhanced use) of telehealth, protocol development, and health care provider training. The research team also identified three barriers to patient throughput: lack of telehealth, lack of resources, and overall lack of knowledge.

CONCLUSIONS

To maintain patient throughput during the COVID-19 pandemic, healthcare organizations need to develop strategies such as the use of virtual consultation and follow-up, new guidelines to move patients along the care delivery value-chain, and ongoing training of providers. Additionally, the availability of required technology for telehealth, availability of resources, and adequate knowledge are vital for continuous patient throughput to ensure continuity of care during a pandemic.

Emergency department provider in triage: assessing site-specific rationale, operational feasibility, and financial impact

Emergency department (ED) crowding is recognized as a critical threat to patient safety, while sub-optimal ED patient flow also contributes to reduced patient satisfaction and efficiency of care. Provider in triage (PIT) programs-which typically involve, at a minimum, a physician or advanced practice provider conducting an initial screening exam and potentially initiating treatment and diagnostic testing at the time of triage-are frequently endorsed as a mechanism to reduce ED length of stay (LOS) and therefore mitigate crowding, improve patient satisfaction, and improve ED operational and financial performance. However, the peer-reviewed evidence regarding the impact of PIT programs on measures including ED LOS, wait times, and costs (as variously defined) is mixed. Mechanistically, PIT programs exert their effects by initiating diagnostic work-ups earlier and, sometimes, by equipping triage providers to directly disposition patients. However, depending on local contextual factors-including the co-existence of other front-end interventions and delays in ED throughput not addressed by PIT-we demonstrate how these features may or may not ultimately translate into reduced ED LOS in different settings. Consequently, site-specific analysis of the root causes of excessive ED LOS, along with mechanistic assessment of potential countermeasures, is essential for appropriate deployment and successful design of PIT programs at individual EDs. Additional motivations for implementing PIT programs may include their potential to enhance patient safety, patient satisfaction, and team dynamics. In this conceptual article, we address a gap in the literature by demonstrating the mechanisms underlying PIT program results and providing a framework for ED decision-makers to assess the local rationale for, operational feasibility of, and financial impact of PIT programs.