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.

BACKGROUNDCrowding 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 5patients 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 SeenTime 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

CONCLUSIONSPhysician 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 hoursand 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