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Chiu DT, Stenson BA, Alghamdi M, Antkowiak PS, Sanchez LD. The association between day of arrival, time of arrival, daily volume and the rate of patients that "left without being seen". Am J Emerg Med 2023; 67:24-28. [PMID: 36780737 DOI: 10.1016/j.ajem.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 01/12/2023] [Accepted: 02/05/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION Patients' left without being seen (LWBS) rate is used as an emergency department (ED) quality indicator. Prior research has investigated characteristics of these patients, but there are minimal studies assessing the impact of departmental variables. We evaluate the LWBS rate at a granular level, looking at its relationship to day of week, hour of arrival and total patient volume. METHODS Retrospective cohort analysis of 109,983 cases from a single academic center. We captured patient disposition, day of week and hour of day of arrival, and total daily volume. Chi-squared test was performed to determine the difference in LWBS rates based on arrival variables. We ran a polynomial regression for LWBS rates by decile of daily patient volume. RESULTS The overall LWBS rate was 1.82% over 2 years. This varied significantly by day of week and hour of day (p < 0.001). Day of week rates ranged from 0.73% on Sunday to 2.45% on Wednesday. Hour of day rates ranged from 0.26% between 8 AM-9 AM, to 3.71% between 10 PM-11 PM. As total daily patient volume increased, LWBS rates gradually increased until the 70th percentile, followed by significant exponential growth afterwards. DISCUSSION LWBS rates are not static measurements, and vary greatly depending on ED circumstances. Weekdays and evenings have significantly higher rates. Additionally, LWBS rates climb above 2% as daily registrations reach the 70th percentile, increasing exponentially at each subsequent decile. Understanding these effects will allow for more effective, targeted interventions to minimize this rate and improve throughput.
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Affiliation(s)
- David T Chiu
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Road, Boston, MA 02215, USA
| | - Bryan A Stenson
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Road, Boston, MA 02215, USA.
| | - Mohammed Alghamdi
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Road, Boston, MA 02215, USA
| | - Peter S Antkowiak
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Road, Boston, MA 02215, USA
| | - Leon D Sanchez
- Brigham and Women's Faulkner Hospital, Department of Emergency Medicine, 1153 Centre Street, Boston, MA 02130, USA
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Implementation of a Standardized Protocol for Telehealth Provider in Triage to Improve Efficiency and ED Throughput. Adv Emerg Nurs J 2022; 44:312-321. [DOI: 10.1097/tme.0000000000000433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Elalouf A, Wachtel G. Queueing Problems in Emergency Departments: A Review of Practical Approaches and Research Methodologies. OPERATIONS RESEARCH FORUM 2022. [PMCID: PMC8716576 DOI: 10.1007/s43069-021-00114-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Problems related to patient scheduling and queueing in emergency departments are gaining increasing attention in theory, in the fields of operations research and emergency and healthcare services, and in practice. This paper aims to provide an extensive review of studies addressing queueing-related problems explicitly related to emergency departments. We have reviewed 229 articles and books spanning seven decades and have sought to organize the information they contain in a manner that is accessible and useful to researchers seeking to gain knowledge on specific aspects of such problems. We begin by presenting a historical overview of applications of queueing theory to healthcare-related problems. We subsequently elaborate on managerial approaches used to enhance efficiency in emergency departments. These approaches include bed management, fast-track, dynamic resource allocation, grouping/prioritization of patients, and triage approaches. Finally, we discuss scientific methodologies used to analyze and optimize these approaches: algorithms, priority models, queueing models, simulation, and statistical approaches.
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Brain D, Johnson D, Hocking J, Chang AT. The economic impact of rostering junior doctors to triage to assist nursing staff in the early part of the patient journey through the emergency department. PLoS One 2021; 16:e0261303. [PMID: 34919596 PMCID: PMC8682888 DOI: 10.1371/journal.pone.0261303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 11/30/2021] [Indexed: 11/18/2022] Open
Abstract
Objective This study aims to determine whether redeploying junior doctors to assist at triage represents good value for money and a good use of finite staffing resources. Methods We undertook a cost-minimisation analysis to produce new evidence, from an economic perspective, about the costs associated with reallocating junior doctors in the emergency department. We built a decision-analytic model, using a mix of prospectively collected data, routinely collected administrative databases and hospital costings to furnish the model. To measure the impact of uncertainty on the model’s inputs and outputs, probabilistic sensitivity analysis was undertaken, using Monte Carlo simulation. Results The mean costs for usual care were $27,035 (95% CI $27,016 to $27,054), while the mean costs for the new model of care were $25,474, (95% CI $25,453 to $25,494). As a result, the mean difference was -$1,561 (95% CI -$1,533 to -$1,588), with the new model of care being a less costly approach to managing staffing allocations, in comparison to the usual approach. Conclusion Our study shows that redeploying a junior doctor from the fast-track area of the department to assist at triage provides a modest reduction in cost. Our findings give decision-makers who seek to maximise benefit from their finite budget, support to reallocate personnel within the ED.
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Affiliation(s)
- David Brain
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology (QUT), Brisbane, Australia
- * E-mail:
| | - David Johnson
- Hervey Bay Hospital Emergency Department, Wide Bay Hospital and Health Service, Queensland Health, Queensland, Australia
| | - Julia Hocking
- Office for Research, Griffith University, Brisbane, Australia
| | - Angela T. Chang
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology (QUT), Brisbane, Australia
- Centre for Allied Health Research, Royal Brisbane and Women’s Hospital, Brisbane, Australia
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Kim TY, Ohmart C, Khan Z, Lance M, Kim S. The Effect on Length of Stay After Implementation of Discharging Low Acuity Patients From Triage. Cureus 2021; 13:e17640. [PMID: 34646688 PMCID: PMC8485874 DOI: 10.7759/cureus.17640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Overcrowding in the emergency department is a complex and challenging issue across the nation. The increasing number of patients seeking care in the emergency department leads to overcrowding and therefore decreased available rooms and slower throughput. As part of a quality improvement project to improve throughput, we implemented a policy encouraging the discharge of non-emergent patients directly from triage. Methods This was a retrospective pre- vs post-implementation analysis of a discharge process from triage to decrease emergency department length of stay. We implemented a policy that allowed the physician assistant to discharge lower acuity patients directly from triage. We collected daily length of stay metrics for a two-week period prior to and a two-week period after the implementation of the policy. Total and daily pre- and post-implementation length of stay means were compared and reported. Results There was a total of 1044 (pre-implementation) and 1063 (post-implementation) patients evaluated during the study period. There was a significant mean difference improvement in the overall length of stay post-implementation of 18.43 minutes (95% CI, 15.45 - 21.40). When comparing the differences for the day of the week, all days showed a statistically significant mean improvement in the length of stay of greater than 10%. Conclusion Discharging low acuity patients directly from triage can lead to a reduction in length of stay. Future studies are needed to determine the impact of different confounders on the length of stay of patients who are discharged from triage, as well as studies to evaluate the outcomes of patients that have been discharged from triage.
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Affiliation(s)
- Tommy Y Kim
- Emergency Medicine, HCA Healthcare, Riverside Community Hospital, Riverside, USA
| | - Connor Ohmart
- Emergency Medicine, HCA Healthcare, Riverside Community Hospital, Riverside, USA
| | - Zara Khan
- Emergency Medicine, HCA Healthcare, Riverside Community Hospital, Riverside, USA
| | - Michael Lance
- Emergency Medicine, HCA Healthcare, Riverside Community Hospital, Riverside, USA
| | - Steven Kim
- Emergency Medicine, HCA Healthcare, Riverside Community Hospital, Riverside, USA
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Anwar MR, Rowe BH, Metge C, Star ND, Aboud Z, Kreindler SA. Realist analysis of streaming interventions in emergency departments. BMJ LEADER 2021. [DOI: 10.1136/leader-2020-000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundSeveral of the many emergency department (ED) interventions intended to address the complex problem of (over)crowding are based on the principle of streaming: directing different groups of patients to different processes of care. Although the theoretical basis of streaming is robust, evidence on the effectiveness of these interventions remains inconclusive.MethodsThis qualitative research, grounded in the population-capacity-process model, sought to determine how, why and under what conditions streaming interventions may be effective. Data came from a broader study exploring patient flow strategies across Western Canada through in-depth interviews with managers at all levels. We undertook realist analysis of interview data from the 98 participants who discussed relevant interventions (fast-track/minor treatment areas, rapid assessment zones, diverse short-stay units), focusing on their explanations of initiatives’ perceived outcomes.ResultsEssential features of streaming interventions included separation of designated populations (population), provision of dedicated space and resources (capacity) and rapid cycle time (process). These features supported key mechanisms of impact: patients wait only for services they need; patient variability is reduced; lag time between steps is eliminated; and provider attitude change promotes prompt discharge. Conversely, reported failures usually involved neglect of one of these dimensions during intervention design and/or implementation. Participants also identified important contextual barriers to success, notably lack of outflow sites and demand outstripping capacity. Nonetheless, failure was more commonly attributed to intervention flaws than to context factors.ConclusionsWhile streaming interventions have the potential to reduce crowding, a theory-based intervention relies on its implementers’ adherence to the theory. Streaming interventions cannot be expected to yield the desired results if operationalised in a manner incongruent with the theory on which they are supposedly based.
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Corkery N, Avsar P, Moore Z, O'Connor T, Nugent L, Patton D. What is the impact of team triage as an intervention on waiting times in an adult emergency department? - A systematic review. Int Emerg Nurs 2021; 58:101043. [PMID: 34352705 DOI: 10.1016/j.ienj.2021.101043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 04/27/2021] [Accepted: 06/10/2021] [Indexed: 12/01/2022]
Abstract
AIM To examine the impact of team triage on waiting times in adult emergency departments. DESIGN A systematic review using narrative analysis. METHOD Systematic review methodology, which included quantitative research papers consisting of randomized control trials, cohort or quasi-experimental studies. The PICO framework was used to formulate the question. Using a structured search, databases were used to source the research papers. Databases searched were Cochrane, CINAHL and MEDLINE. Twelve (12) research papers met the inclusion criteria. Each of the 12 papers were quality appraised using a recognised checklist. Data extraction was carried out and the findings were analysed using a narrative approach. RESULTS It was found that senior emergency doctors in triage alongside the triage nurse allows for more timely decision making and appropriate investigation orders. Early bed requesting or referral to specialist consultation were also found to improve waiting times. Reduced numbers of patients who leave without being seen and lower mortality rates were recorded when using team triage. Patient satisfaction is also improved by team triage. CONCLUSION Team triage improves waiting times in the emergency department.
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Affiliation(s)
- Nessa Corkery
- St. Vincent's University Hospital, Dublin 4, Ireland; School of Nursing, The Royal College of Surgeons of Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland.
| | - Pinar Avsar
- Skin Wounds and Trauma Research Centre, The Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland
| | - Zena Moore
- Head of School of Nursing and Midwifery and Director of the Skin Wounds and Trauma Research Centre, The Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland; Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Belgium; Lida Institute, Shanghai, China
| | - Tom O'Connor
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; Lida Institute, Shanghai, China; Director of Academic Affairs and Deputy Head of School, School of Nursing and Midwifery and Lead Researcher, Skin Wounds and Trauma Research Centre, The Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland
| | - Linda Nugent
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; Lecturer and Programme Director, School of Nursing and Midwifery. The Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland
| | - Declan Patton
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; Director of Nursing and Midwifery Research and Deputy Director of the Skin, Wounds and Trauma Research Centre, School of Nursing and Midwifery, The Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland; Honorary Senior Fellow, Faculty of Science, Medicine and Health, University of Wollongong, Australia
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Spiegelman L, Jen M, Matonis D, Gibney R, Soheil S, Sakaria S, Wray A, Toohey S. The Effects of Implementing a “Waterfall” Emergency Physician Attending Schedule. West J Emerg Med 2021; 22:882-889. [PMID: 35353992 PMCID: PMC8328172 DOI: 10.5811/westjem.2021.2.50249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/26/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction: Increases in emergency department (ED) crowding and boarding are a nationwide issue resulting in worsening patient care and throughput. To compensate, ED administrators often look to modifying staffing models to improve efficiencies.
Methods: This study evaluates the impact of implementing the waterfall model of physician staffing on door-to-doctor time (DDOC), door-to-disposition time (DDIS), left without being seen (LWBS) rate, elopement rate, and the number of patient sign-outs. We examined 9,082 pre-intervention ED visits and 8,983 post-intervention ED visits.
Results: The change in DDOC, LWBS rate, and elopement rate demonstrated statistically significant improvement from a mean of 65.1 to 35 minutes (P <0.001), 1.12% to 0.92% (P = 0.004), and 3.96% to 1.95% (P <0.001), respectively. The change in DDIS from 312 to 324.7 minutes was not statistically significant (P = 0.310). The number of patient sign-outs increased after the implementation of a waterfall schedule (P <0.001).
Conclusion: Implementing a waterfall schedule improved DDOC time while decreasing the percentage of patients who LWBS and eloped. The DDIS and number of patient sign-outs appears to have increased post implementation, although this may have been confounded by the increase in patient volumes and ED boarding from the pre- to post-intervention period.
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Affiliation(s)
- Lindsey Spiegelman
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Maxwell Jen
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Danielle Matonis
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Ryan Gibney
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Saadat Soheil
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Sangeeta Sakaria
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Alisa Wray
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Shannon Toohey
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
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Dreher-Hummel T, Nickel CH, Nicca D, Grossmann FF. The challenge of interprofessional collaboration in emergency department team triage - An interpretive description. J Adv Nurs 2020; 77:1368-1378. [PMID: 33245167 DOI: 10.1111/jan.14675] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/28/2020] [Accepted: 10/30/2020] [Indexed: 01/10/2023]
Abstract
AIMS To explore emergency nurses' and physicians' experience of collaboration and collective decision-making when triaging older Emergency Department patients within the interprofessional team triage system. DESIGN Qualitative. METHODS Semi-structured interviews were conducted with seven nurses and five physicians. Transcripts were analysed via Interpretive Description between September 2016-May 2017. RESULTS 'Negotiating collaboration' was developed as the main theme. Three subthemes influenced the negotiation process: Participants described divergent opinions on how an optimal triage system should work ('preferences for triage systems'); they had conflicting perceptions of each profession's role ('role perceptions'); and they expressed different coping strategies regarding 'perceived time pressure'. The compatibility of participants' views on these sub-themes determined whether the nurse and physician were able to successfully negotiate their collaboration. These themes became more evident when the team triaged older ED patients. CONCLUSION Improving interprofessional team triage requires working with the involved nurses' and physicians' values and beliefs. The strengths of both professions need to be considered and a flexible approach to collaboration established according to the patients' situations. IMPACT Emergency Department leaders need to consider nurses' and physicians' values and beliefs to promote interprofessional collaboration in team triage.
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Affiliation(s)
| | | | - Dunja Nicca
- Department of Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Florian F Grossmann
- Department of Medicine, Division of Nursing, Emergency Department, University Hospital Basel, Basel, Switzerland
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10
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The cost of waiting: Association of ED boarding with hospitalization costs. Am J Emerg Med 2020; 40:169-172. [PMID: 33272871 DOI: 10.1016/j.ajem.2020.10.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/29/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Emergency Department (ED) boarding, the practice of holding patients in the ED after they have been admitted to the hospital due to unavailability of inpatient beds, is common and contributes to the public health crisis of ED crowding. Prior work has documented the harms of ED boarding on access and quality of care. Limited studies examine the relationship between ED boarding and an equally important domain of quality-the cost of care. This study evaluates the relationship between ED boarding, ED characteristics and risk-adjusted hospitalization costs utilizing national publicly-reported measures. METHODS We conducted a cross-sectional analysis of two 2018 Centers for Medicare and Medicaid Services (CMS) Hospital Compare datasets: 1) Medicare Hospital Spending per Patient and 2) Timely and Effective Care. We constructed a hospital-level multivariate linear regression analysis to examine the association between ED boarding and Medicare spending per beneficiary (MSPB), adjusting for ED length of stay, door to diagnostic evaluation time, and ED patient volume. RESULTS A total of 2903 hospitals were included in the analysis. ED boarding was significantly correlated with MSPB (r = 0.1774; p-value: < 0.0001). In multivariate regression, ED boarding was also positively associated with MSPB (Beta: 0.00015; p < 0.0001) after adjustment for other hospital level crowding indicators. CONCLUSION We found a strong relationship between measures of ED crowding, including ED boarding, and risk-adjusted hospital spending. Future work should elucidate the mediators of this relationship. Policymakers and administrators should consider the financial harms of ED boarding when devising strategies to improve hospital care access and flow.
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Abstract
Early assignment of patients to specific treatment teams improves length of stay, rate of patients leaving without being seen, patient satisfaction, and resident education. Multiple variations of patient assignment systems exist, including provider-in-triage/team triage, fast-tracks/vertical pathways, and rotational patient assignment. The authors discuss the theory behind patient assignment systems and review potential benefits of specific models of patient assignment found in the current literature.
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12
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Shah R, Leno R, Sinert R. Impact of Provider-In-Triage in a Safety-Net Hospital. J Emerg Med 2020; 59:459-465. [PMID: 32595053 DOI: 10.1016/j.jemermed.2020.04.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/17/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Increasing emergency department (ED) utilization has contributed to ED overcrowding, with longer ED length of stay (EDLOS) and more patients leaving without being seen (LWBS), and is associated with higher morbidity and mortality rates. Previous studies of provider in triage (PIT) have shown decreased LWBS, but variable improvements in EDLOS. OBJECTIVES We evaluated the impact of PIT implementation in an urban safety-net hospital on commonly reported ED throughput metrics. METHODS This before-and-after study was performed at an academic urban safety hospital. We implemented a PIT team that screened ambulatory ED patients for early discharge or expedited workup. The PIT intervention was implemented 3 days a week from January through April 2019. As controls, we compared throughput metrics from when PIT was unavailable (Group 2) and from 1 year prior (Group 3). RESULTS There were significantly (p < 0.001) lower rates of LWBS in Group 1 (4.8%, 95% confidence interval [CI] 4.1-5.8%) compared with 2 (7.3%, 95% CI 5.5-9.7%) and 3 (7.8%, 95% CI 6.9-9.0%). Door-to-doctor times were significantly (p < 0.001) lower for Group 1 (148 min, interquartile range [IQR] 88, 226 min) compared with 2 (187 min, IQR 95.5, 266 min) and 3 (215 min, IQR 131, 290 min). EDLOS was significantly (p < 0.001) shorter for Group 1 (337 min, IQR 215, 468 min) compared with 2 (385 min, IQR 271, 516 min) and 3 (413 min, IQR 299, 538 min). CONCLUSIONS We found significantly lower LWBS rates, shorter EDLOS, and shorter door-to-doctor times after PIT implementation. Compared with previous studies in a variety of settings, we found that PIT significantly improved LWBS and all throughput metrics in a safety net setting.
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Affiliation(s)
- Rushabh Shah
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, New York; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Richard Leno
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, New York; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Richard Sinert
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, New York; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York
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Benabbas R, Shah R, Zonnoor B, Mehta N, Sinert R. Impact of triage liaison provider on emergency department throughput: A systematic review and meta-analysis. Am J Emerg Med 2020; 38:1662-1670. [PMID: 32505473 DOI: 10.1016/j.ajem.2020.04.068] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Emergency department (ED) overcrowding is linked to poor outcome and decreases patient satisfaction. Strategies to control Emergency department (ED) overcrowding has been subject of research. STUDY OBJECTIVES The objective of this systematic review and meta-analysis was to investigate the impact of triage liaison providers (TLPs) on the ED throughput. METHODS We searched PubMed, EMBASE, and Web of Science up to April 2019 for studies done in the United States. Primary outcomes were number of patients left without being seen (LWBS) and patients' emergency department length of stay (ED-LOS). ED-LOS data was pooled using mean difference with random effect model. Risk Ratio (RRs) for LWBS was calculated with random effect model with 95% confidence interval (95% CI). RESULTS Twelve studies encompassing 329,340patients were included in the meta-analysis. Implementation of the TLP system using attending physicians was associated with a decrease in risk of LWBS 0.62 (95% CI 0.54, 0.71), The change in ED-LOS after implementation of TLP was too heterogeneous to pool the data with the mean ΔED-LOS ranging from -82 to +20 min. Stratification of studies by disposition, admitted versus discharged, did not decrease the heterogeneity. CONCLUSION Implementation of TLP can decrease the rate of LWBS however this review is inconclusive about the effect of TLP on ED-LOS due to the high heterogeneity observed in the literature.
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Affiliation(s)
- Roshanak Benabbas
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, United States of America; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, United States of America.
| | - Rushabh Shah
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, United States of America; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, United States of America
| | - Bobak Zonnoor
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, United States of America; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, United States of America
| | - Ninfa Mehta
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, United States of America; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, United States of America
| | - Richard Sinert
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, United States of America; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, United States of America
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Snozek CLH, Hernandez JS, Traub SJ. “Rainbow Draws” in the Emergency Department: Clinical Utility and Staff Perceptions. J Appl Lab Med 2019; 4:229-234. [DOI: 10.1373/jalm.2018.027649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 09/07/2018] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Collecting a predefined set of blood tubes (the “rainbow draw”) is a common but controversial practice in many emergency departments (EDs), with limited data to support it. We determined the actual utilization of rainbow draw tubes at a single facility and evaluated the perceptions of ED staff regarding the utility of rainbow draws.
Methods
We analyzed 2 weeks of ED visits (1326 visits by 1240 unique patients) to determine blood tube utilization for initial and add-on testing, as well as the incidence of additional venipunctures. We also surveyed ED staff regarding aspects of ED phlebotomy and test ordering. Utilization data analysis was structured to satisfy specific concerns addressed in the ED staff survey.
Results
Observed tube utilization data showed that fluoride/oxalate, citrate, and serum separator tubes were frequently discarded unused, and that the actual utility of the rainbow draw for add-on testing and avoiding additional venipunctures was low. ED staff perceived that the rainbow draw was highly valuable, both to expedite add-on testing and to avoid additional venipunctures. Contrasting the objective (utilization data) and subjective (survey results) to drive changes in the standard ED blood collection reduced the estimated waste blood by 175 L/year.
Conclusions
Comparison of perceptions and objective utilization data drove process changes that were mutually agreeable to ED and laboratory staff. Although specifics of ED and laboratory work flows vary between institutions, the principles and strategy of this study are widely applicable.
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Affiliation(s)
- Christine L H Snozek
- Department of Laboratory Medicine and Pathology, Mayo Clinic in Arizona, Phoenix, AZ
| | - James S Hernandez
- Department of Laboratory Medicine and Pathology, Mayo Clinic in Arizona, Phoenix, AZ
| | - Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic in Arizona, Phoenix, AZ
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Anderson JS, Burke RC, Augusto KD, Beagan BM, Rodrigues-Belong ML, Frazer LS, Stack C, Shukla A, Pope JV. The Effect of a Rapid Assessment Zone on Emergency Department Operations and Throughput. Ann Emerg Med 2019; 75:236-245. [PMID: 31668573 DOI: 10.1016/j.annemergmed.2019.07.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 07/12/2019] [Accepted: 07/30/2019] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE We examine the effects of a front-end flow model designated the rapid assessment zone on multiple emergency department (ED) operational metrics. METHODS This was a retrospective, before-after study of consecutive patient visits at an urban community ED. Six-month periods were compared before and after an intervention in 2017 that changed patient flow and the intake process. A lead nurse role splits patient flow immediately on patient arrival according to only age and chief complaint, allowing direct bedding without the bottlenecks of vital sign measurement, full triage assessment, or Emergency Severity Index assignment. A new patient care area (designated rapid assessment zone) preferentially expedites treatment of patients likely to remain ambulatory and serves as flexible acute care space when needed by individual cases and the ED. The outcomes measured were ED length of stay, arrival-to-provider time, the rate of leaving before treatment completion, and the rate of leaving before being seen. Data were analyzed with nonparametric testing, χ2 analysis, and multiple linear regression, controlling for patient visit characteristics, ED daily census volumes, and measurements of boarding patients. RESULTS We analyzed 43,847 visits in the preintervention and 44,792 visits in the postintervention periods. The intervention was associated with the following changes: median ED length of stay from 203 to 171 minutes (-15.8%), median arrival-to-provider time from 28 to 13 minutes (-53.6%), leaving before treatment completion from 1.0% to 0.8% (-20%), and leaving before being seen from 3.1% to 0.5% (-84%). Regression analysis accounting for multiple confounders demonstrated that the reduced length of stay after rapid assessment zone implementation persisted across Emergency Severity Index levels 2 to 5 and all ED daily census levels. CONCLUSION The rapid assessment zone model aims to decrease front-end bottlenecks and minimize serial intake assessments at a high-volume, urban ED. It was associated with improved patient throughput and decreased early patient departure. It may represent a useful model for similar centers.
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Affiliation(s)
- Jared S Anderson
- Department of Emergency Medicine, St. Luke's Hospital, New Bedford, MA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
| | - Ryan C Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Kevin D Augusto
- Operational Excellence and Business Operations Departments, Southcoast Health New Bedford, MA
| | - Brianne M Beagan
- Operational Excellence and Business Operations Departments, Southcoast Health New Bedford, MA
| | | | - Lori S Frazer
- Emergency Services Department, Southcoast Health, New Bedford, MA
| | - Colin Stack
- Department of Emergency Medicine, St. Luke's Hospital, New Bedford, MA
| | - Anil Shukla
- Department of Emergency Medicine, St. Luke's Hospital, New Bedford, MA
| | - Jen V Pope
- Department of Emergency Medicine, St. Luke's Hospital, New Bedford, MA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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Triage to Observation: A Quality Improvement Initiative for Chest Pain Patients Presenting to the Emergency Department. Crit Pathw Cardiol 2019; 18:75-79. [PMID: 31094733 DOI: 10.1097/hpc.0000000000000175] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the impact of a rapid admission protocol for chest pain patients presenting to the emergency department (ED) on ED length-of-stay (LOS). In this study, ED LOS was defined as the time from triage check-in until the time the patient physically leaves the ED. The purpose of this quality improvement study was to decrease ED crowding. METHODS This is a single-center prospective cohort study performed as a quality improvement initiative. This study implemented a rapid admission protocol for patients who were at moderate risk for a major adverse cardiac event based on the HEART score. When a patient presented to the ED through triage with a chief complaint of chest pain, this protocol allowed the provider-in-triage (PIT) to identify eligible patients for potential rapid admission to the hospital's clinical decision unit (CDU). The PIT would complete a rapid medical screening examination, initiate the patient's workup, and call the CDU providers to further evaluate the patient. By identifying these patients early, the lengthy ED chest pain workup contributing to longer ED LOS could then be completed in the CDU. RESULTS The total number of patients seen in the ED over the study period was 34,251. The total number of patients admitted to the CDU during the study period was 1,442. The PIT identified 13 patients for rapid admission to the CDU during the study period. These patients had a statistically significant reduction in ED LOS (P < 0.001). ED LOS was also adjusted to identify delays in patient movement resulting in a statistically significant difference (P < 0.001). CONCLUSION Implementation of a rapid admission protocol for chest pain patients at moderate risk for a major adverse cardiac event resulted in a reduction in ED LOS. Adjusted ED LOS was also significant, highlighting a delay in patient movement from the ED to the CDU indicating continued barriers affecting ED holding times.
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Spencer S, Stephens K, Swanson-Biearman B, Whiteman K. Health Care Provider in Triage to Improve Outcomes. J Emerg Nurs 2019; 45:561-566. [PMID: 30827577 DOI: 10.1016/j.jen.2019.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/02/2019] [Accepted: 01/15/2019] [Indexed: 11/25/2022]
Abstract
PROBLEM Emergency departments throughout the nation are experiencing crowding related to increased patient volumes and decreased hospital inpatient bed capacity. As a result of lengthy wait times, patients are leaving without having medical treatment, and satisfaction is poor. The purpose of this quality improvement initiative was placing a provider in triage to complement the existing split-flow process aimed to decrease wait times to see a provider, length of stay (LOS), left without being seen (LWBS) rates, and improve patient satisfaction. METHODS A multiprofessional team was established. Nurses, advanced practice providers, and physicians collaborated on a project to place a provider in triage to assist in seeing patients as soon as possible and begin care or treatment. RESULTS The outcomes of the initiative were positive for ED LOS metrics and patient satisfaction. Door-to-provider time decreased from a high of 56 minutes to a low of 13 minutes. The percentage of patients LWBS decreased from a high of 12% to a low of 1.62%. DISCUSSION The project showed that the evidence-based practice of a combined split-flow and provider-in-triage model resulted in improvements in throughput for patients who were treated and released from the emergency department.
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Liu J, Masiello I, Ponzer S, Farrokhnia N. Can interprofessional teamwork reduce patient throughput times? A longitudinal single-centre study of three different triage processes at a Swedish emergency department. BMJ Open 2018; 8:e019744. [PMID: 29674366 PMCID: PMC5914774 DOI: 10.1136/bmjopen-2017-019744] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine the impact on emergency department (ED) throughput times and proportion of patients who leave without being seen by a physician (LWBS) of two triage interventions, where comprehensive nurse-led triage was first replaced by senior physician-led triage and then by interprofessional teamwork. DESIGN Single-centre before-and-after study. SETTING Adult ED of a Swedish urban hospital. PARTICIPANTS Patients arriving on weekdays 08:00 to 21:00 during three 1-year periods in the interval May 2012 to November 2015. A total of 185 806 arrivals were included. INTERVENTIONS Senior physicians replaced triage nurses May 2013 to May 2014. Interprofessional teamwork replaced the triage process on weekdays 08:00 to 21:00 November 2014 to November 2015. MAIN OUTCOME MEASURES Primary outcomes were the median time to physician (TTP) and the median length of stay (LOS). Secondary outcome was the LWBS rate. RESULTS The crude median LOS was shortest for teamwork, 228 min (95% CI 226.4 to 230.5) compared with 232 min (95% CI 230.8 to 233.9) for nurse-led and 250 min (95% CI 248.5 to 252.6) for physician-led triage. The adjusted LOS for the teamwork period was 16 min shorter than for nurse-led triage and 23 min shorter than for physician-led triage. The median TTP was shortest for physician-led triage, 56 min (95% CI 54.5 to 56.6) compared with 116 min (95% CI 114.4 to 117.5) for nurse-led triage and 74 min (95% CI 72.7 to 74.8) for teamwork. The LWBS rate was 1.9% for nurse-led triage, 1.2% for physician-led triage and 3.2% for teamwork. All outcome measure differences had two-tailed p values<0.01. CONCLUSIONS Interprofessional teamwork had the shortest length of stay, a shorter time to physician than nurse-led triage, but a higher LWBS rate. Interprofessional teamwork may be a useful approach to reducing ED throughput times.
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Affiliation(s)
- Jenny Liu
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Italo Masiello
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Sari Ponzer
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Nasim Farrokhnia
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
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Traub SJ, Saghafian S, Judson K, Russi C, Madsen B, Cha S, Tolson HC, Sanchez LD, Pines JM. Interphysician Differences in Emergency Department Length of Stay. J Emerg Med 2018; 54:702-710.e1. [PMID: 29454714 DOI: 10.1016/j.jemermed.2017.12.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 11/27/2017] [Accepted: 12/17/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Emergency physicians differ in many ways with respect to practice. One area in which interphysician practice differences are not well characterized is emergency department (ED) length of stay (LOS). OBJECTIVE To describe how ED LOS differs among physicians. METHODS We performed a 3-year, five-ED retrospective study of non-fast-track visits evaluated primarily by physicians. We report each provider's observed LOS, as well as each provider's ratio of observed LOS/expected LOS (LOSO/E); we determined expected LOS based on site average adjusted for the patient characteristics of age, gender, acuity, and disposition status, as well as the time characteristics of shift, day of week, season, and calendar year. RESULTS Three hundred twenty-seven thousand, seven hundred fifty-three visits seen by 92 physicians were eligible for analysis. For the five sites, the average shortest observed LOS was 151 min (range 106-184 min), and the average longest observed LOS was 232 min (range 196-270 min); the average difference was 81 min (range 69-90 min). For LOSO/E, the average lowest LOSO/E was 0.801 (range 0.702-0.887), and the average highest LOSO/E was 1.210 (range 1.186-1.275); the average difference between the lowest LOSO/E and the highest LOSO/E was 0.409 (range 0.305-0.493). CONCLUSION There are significant differences in ED LOS at the level of the individual physician, even after accounting for multiple confounders. We found that the LOSO/E for physicians with the lowest LOSO/E at each site averaged approximately 20% less than predicted, and that the LOSO/E for physicians with the highest LOSO/E at each site averaged approximately 20% more than predicted.
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Affiliation(s)
- Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona; College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Soroush Saghafian
- Harvard Kennedy School, Harvard University, Cambridge, Massachusetts
| | - Kurtis Judson
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona; College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christopher Russi
- College of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bo Madsen
- College of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Stephen Cha
- Division of Health Systems Informatics, Mayo Clinic Arizona, Phoenix, Arizona
| | - Hannah C Tolson
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Leon D Sanchez
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts
| | - Jesse M Pines
- Department of Emergency Medicine and Health Policy & Management, George Washington University, Washington, DC
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Traub SJ, Saghafian S, Bartley AC, Buras MR, Stewart CF, Kruse BT. The durability of operational improvements with rotational patient assignment. Am J Emerg Med 2018; 36:1367-1371. [PMID: 29331271 DOI: 10.1016/j.ajem.2017.12.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/14/2017] [Accepted: 12/20/2017] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Previous work has suggested that Emergency Department rotational patient assignment (a system in which patients are algorithmically assigned to physicians) is associated with immediate (first-year) improvements in operational metrics. We sought to determine if these improvements persisted over a longer follow-up period. METHODS Single-site, retrospective analysis focused on years 2-4 post-implementation (follow-up) of a rotational patient assignment system. We compared operational data for these years with previously published data from the last year of physician self-assignment and the first year of rotational patient assignment. We report data for patient characteristics, departmental characteristics and facility characteristics, as well as outcomes of length of stay (LOS), arrival to provider time (APT), and rate of patients who left before being seen (LBBS). RESULTS There were 140,673 patient visits during the five year period; 138,501 (98.7%) were eligible for analysis. LOS, APT, and LBBS during follow-up remained improved vs. physician self-assignment, with improvements similar to those noted in the first year of implementation. Compared with the last year of physician self-assignment, approximate yearly average improvements during follow-up were a decrease in median LOS of 18min (8% improvement), a decrease in median APT of 21min (54% improvement), and a decrease in LBBS of 0.69% (72% improvement). CONCLUSION In a single facility study, rotational patient assignment was associated with sustained operational improvements several years after implementation. These findings provide further evidence that rotational patient assignment is a viable strategy in front-end process redesign.
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Affiliation(s)
- Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States; College of Medicine, Mayo Clinic, Rochester, MN, United States.
| | | | - Adam C Bartley
- Division of Health Systems Informatics, Mayo Clinic, Rochester, MN, United States
| | - Matthew R Buras
- Division of Health Sciences Research, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Christopher F Stewart
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States; College of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Brian T Kruse
- College of Medicine, Mayo Clinic, Rochester, MN, United States; Department of Emergency Medicine, Mayo Clinic Florida, Jacksonville, FL, United States
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Balfour ME, Tanner K, Jurica PJ, Llewellyn D, Williamson RG, Carson CA. Using Lean to Rapidly and Sustainably Transform a Behavioral Health Crisis Program: Impact on Throughput and Safety. Jt Comm J Qual Patient Saf 2017; 43:275-283. [PMID: 28528621 DOI: 10.1016/j.jcjq.2017.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lean has been increasingly applied in health care to reduce waste and improve quality, particularly in fast-paced and high-acuity clinical settings such as emergency departments. In addition, Lean's focus on engagement of frontline staff in problem solving can be a catalyst for organizational change. In this study, ConnectionsAZ demonstrates how they applied Lean principles to rapidly and sustainably transform clinical operations in a behavioral health crisis facility. METHODS A multidisciplinary team of management and frontline staff defined values-based outcome measures, mapped the current and ideal processes, and developed new processes to achieve the ideal. Phase I was implemented within three months of assuming management of the facility and involved a redesign of flow, space utilization, and clinical protocols. Phase II was implemented three months later and improved the provider staffing model. Organizational changes such as the development of shift leads and daily huddles were implemented to sustain change and create an environment supportive of future improvements. RESULTS Post-Phase I, there were significant decreases (pre vs. post and one-year post) in median door-to-door dwell time (343 min vs. 118 and 99), calls to security for behavioral emergencies (13.5 per month vs. 4.3 and 4.8), and staff injuries (3.3 per month vs. 1.2 and 1.2). Post-Phase II, there were decreases in median door-to-doctor time (8.2 hours vs. 1.6 and 1.4) and hours on diversion (90% vs. 17% and 34%). CONCLUSIONS Lean methods can positively affect safety and throughput and are complementary to patient-centered clinical goals in a behavioral health setting.
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Lauks J, Mramor B, Baumgartl K, Maier H, Nickel CH, Bingisser R. Medical Team Evaluation: Effect on Emergency Department Waiting Time and Length of Stay. PLoS One 2016; 11:e0154372. [PMID: 27104911 PMCID: PMC4841508 DOI: 10.1371/journal.pone.0154372] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 04/12/2016] [Indexed: 11/18/2022] Open
Abstract
Emergency Departments (ED) are trying to alleviate crowding using various interventions. We assessed the effect of an alternative model of care, the Medical Team Evaluation (MTE) concept, encompassing team triage, quick registration, redesign of triage rooms and electronic medical records (EMR) on door-to-doctor (waiting) time and ED length of stay (LOS). We conducted an observational, before-and-after study at an urban academic tertiary care centre. On July 17th 2014, MTE was initiated from 9:00 a.m. to 10 p.m., 7 days a week. A registered triage nurse was teamed with an additional senior ED physician. Data of the 5-month pre-MTE and the 5-month MTE period were analysed. A matched comparison of waiting times and ED LOS of discharged and admitted patients pertaining to various Emergency Severity Index (ESI) triage categories was performed based on propensity scores. With MTE, the median waiting times improved from 41.2 (24.8–66.6) to 10.2 (5.7–18.1) minutes (min; P < 0.01). Though being beneficial for all strata, the improvement was somewhat greater for discharged, than for admitted patients. With a reduction from 54.3 (34.2–84.7) to 10.5 (5.9–18.4) min (P < 0.01), in terms of waiting times, MTE was most advantageous for ESI4 patients. The overall median ED LOS increased for about 15 min (P < 0.01), increasing from 3.4 (2.1–5.3) to 3.7 (2.3–5.6) hours. A significant increase was observed for all the strata, except for ESI5 patients. Their median ED LOS dropped by 73% from 1.2 (0.8–1.8) to 0.3 (0.2–0.5) hours (P < 0.01). In the same period the total orders for diagnostic radiology increased by 1,178 (11%) from 10,924 to 12,102 orders, with more imaging tests being ordered for ESI 2, 3 and 4 patients. Despite improved waiting times a decrease of ED LOS was only seen in ESI level 5 patients, whereas in all the other strata ED LOS increased. We speculate that this was brought about by the tendency of triage physicians to order more diagnostic radiology, anticipating that it may be better for the downstream physician to have more information rather than less.
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Affiliation(s)
- Juliane Lauks
- Department of Information and Communications Technology, University of Basel Hospital, Basel, Switzerland
| | - Blaz Mramor
- Freiburg Institute of Advanced Studies, University of Freiburg, Freiburg, Germany
| | - Klaus Baumgartl
- Department of Information and Communications Technology, University of Basel Hospital, Basel, Switzerland
| | - Heinrich Maier
- Department of Information and Communications Technology, University of Basel Hospital, Basel, Switzerland
| | | | - Roland Bingisser
- Emergency Department, University of Basel Hospital, Basel, Switzerland
- * E-mail:
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Traub SJ, Bartley AC, Smith VD, Didehban R, Lipinski CA, Saghafian S. Physician in Triage Versus Rotational Patient Assignment. J Emerg Med 2016; 50:784-90. [PMID: 26826767 DOI: 10.1016/j.jemermed.2015.11.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 11/07/2015] [Accepted: 11/20/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Physician in triage and rotational patient assignment are different front-end processes that are designed to improve patient flow, but there are little or no data comparing them. OBJECTIVE To compare physician in triage with rotational patient assignment with respect to multiple emergency department (ED) operational metrics. METHODS Design-Retrospective cohort review. Patients-Patients seen on 23 days on which we utilized a physician in triage with those patients seen on 23 matched days when we utilized rotational patient assignment. RESULTS There were 1,869 visits during physician in triage and 1,906 visits during rotational patient assignment. In a simple comparison, rotational patient assignment was associated with a lower median length of stay (LOS) than physician in triage (219 min vs. 233 min; difference of 14 min; 95% confidence interval [CI] 5-27 min). In a multivariate linear regression incorporating multiple confounders, there was a nonsignificant reduction in the geometric mean LOS in rotational patient assignment vs. physician in triage (204 min vs. 217 min; reduction of 6.25%; 95% CI -3.6% to 15.2%). There were no significant differences between groups for left before being seen, left subsequent to being seen, early (within 72 h) returns, early returns with admission, or complaint ratio. CONCLUSIONS In a single-site study, there were no statistically significant differences in important ED operational metrics between a physician in triage model and a rotational patient assignment model after adjusting for confounders.
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Affiliation(s)
- Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona; College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Adam C Bartley
- Department of Health Science Research, Mayo Clinic, Rochester, Minnesota
| | - Vernon D Smith
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona; College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Roshanak Didehban
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona; College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christopher A Lipinski
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona; College of Medicine, Mayo Clinic, Rochester, Minnesota
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Traub SJ, Stewart CF, Didehban R, Bartley AC, Saghafian S, Smith VD, Silvers SM, LeCheminant R, Lipinski CA. Emergency Department Rotational Patient Assignment. Ann Emerg Med 2015; 67:206-15. [PMID: 26452721 DOI: 10.1016/j.annemergmed.2015.07.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 06/19/2015] [Accepted: 07/01/2015] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE We compare emergency department (ED) operational metrics obtained in the first year of a rotational patient assignment system (in which patients are assigned to physicians automatically according to an algorithm) with those obtained in the last year of a traditional physician self-assignment system (in which physicians assigned themselves to patients at physician discretion). METHODS This was a pre-post retrospective study of patients at a single ED with no financial incentives for physician productivity. Metrics of interest were length of stay; arrival-to-provider time; rates of left before being seen, left subsequent to being seen, early returns (within 72 hours), and early returns with admission; and complaint ratio. RESULTS We analyzed 23,514 visits in the last year of physician self-assignment and 24,112 visits in the first year of rotational patient assignment. Rotational patient assignment was associated with the following improvements (percentage change): median length of stay 232 to 207 minutes (11%), median arrival to provider time 39 to 22 minutes (44%), left before being seen 0.73% to 0.36% (51%), and complaint ratio 9.0/1,000 to 5.4/1,000 (40%). There were no changes in left subsequent to being seen, early returns, or early returns with admission. CONCLUSION In a single facility, the transition from physician self-assignment to rotational patient assignment was associated with improvement in a broad array of ED operational metrics. Rotational patient assignment may be a useful strategy in ED front-end process redesign.
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Affiliation(s)
- Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ; College of Medicine, Mayo Clinic, Rochester, MN.
| | - Christopher F Stewart
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ; College of Medicine, Mayo Clinic, Rochester, MN
| | - Roshanak Didehban
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ; College of Medicine, Mayo Clinic, Rochester, MN
| | - Adam C Bartley
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Soroush Saghafian
- College of Medicine, Mayo Clinic, Rochester, MN; School of Computing, Informatics and Decision Systems Engineering, Arizona State University, Tempe, AZ
| | - Vernon D Smith
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ; College of Medicine, Mayo Clinic, Rochester, MN
| | - Scott M Silvers
- College of Medicine, Mayo Clinic, Rochester, MN; Department of Emergency Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Ryan LeCheminant
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Christopher A Lipinski
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ; College of Medicine, Mayo Clinic, Rochester, MN
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