Physician-led team triage based on lean principles may be superior for efficiency and quality? A comparison of three emergency departments with different triage models

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Mats Enlund¹  Marie-Louise Engström¹  Tony Wiklund¹  Maaret Castrén³  Göran Örnung²  Martin Nordberg³  Lena Burström¹ 

[1] Centre for Clinical Research, Uppsala University, Central Hospital, Västerås, Sweden;Capio S:t Görans Hospital, Stockholm, Sweden;Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset and Section of Emergency Medicine, Stockholm, Sweden

关键词: Nurse;    Emergency physicians;    Mortality;    Efficiency indicators;    Quality indicators;    Emergency department;    Lean principles;    Teamtriage;   

Others  :  826403
DOI  :  10.1186/1757-7241-20-57

 received in 2012-02-24, accepted in 2012-08-16,  发布年份 2012

【 摘 要 】

Background

The management of emergency departments (EDs) principally involves maintaining effective patient flow and care. Different triage models are used today to achieve these two goals. The aim of this study was to compare the performance of different triage models used in three Swedish EDs. Using efficiency and quality indicators, we compared the following triage models: physician-led team triage, nurse first/emergency physician second, and nurse first/junior physician second.

Methods

All data of patients arriving at the three EDs between 08:00- and 21:00 throughout 2008 were collected and merged into a database. The following efficiency indicators were measured: length of stay (LOS) including time to physician, time from physician to discharge, and 4-hour turnover rate. The following quality indicators were measured: rate of patients left before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days.

Results

Data from 147,579 patients were analysed. The median length of stay was 158 minutes for physician-led team triage, compared with 243 and 197 minutes for nurse/emergency physician and nurse/junior physician triage, respectively (p < 0.001). The rate of patients left before treatment was completed was 3.1% for physician-led team triage, 5.3% for nurse/emergency physician, and 9.6% for nurse/junior physician triage (p < 0.001). Further, the rates of unscheduled return within 24 hours were significantly lower for physician-led team triage, 1.0%, compared with 2.1%, and 2.5% for nurse/emergency physician, and nurse/junior physician, respectively (p < 0.001). The mortality rate within 7 days was 0.8% for physician-led team triage and 1.0% for the two other triage models (p < 0.001).

Conclusions

Physician-led team triage seemed advantageous, both expressed as efficiency and quality indicators, compared with the two other models.

【 授权许可】

   
2012 Burström et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Cowan RM, Trzeciak S: Clinical review: Emergency department overcrowding and the potential impact on the critically ill. Crit Care 2005, 9:291-295. BioMed Central Full Text
• [2]Knapman M, Bonner A: Overcrowding in medium-volume emergency departments: effects of aged patients in emergency departments on wait times for non-emergent triage-level patients. Int J Nurs Pract 2010, 16:310-317.
• [3]Steele R, Kiss A: EMDOC (Emergency Department overcrowding) Internet-based safety net research. J Emerg Med 2008, 35:101-107.
• [4]Trzeciak S, Rivers EP: Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J 2003, 20:402-405.
• [5]Boudreaux ED, O'Hea EL: Patient satisfaction in the Emergency Department: a review of the literature and implications for practice. J Emerg Med 2004, 26:13-26.
• [6]Taylor C, Benger JR: Patient satisfaction in emergency medicine. Emerg Med J 2004, 21:528-532.
• [7]Trout A, Magnusson AR, Hedges JR: Patient satisfaction investigations and the emergency department: what does the literature say? Acad Emerg Med 2000, 7:695-709.
• [8]Rowe BH, Channan P, Bullard M, Blitz S, Saunders LD, Rosychuk RJ, Lari H, Craig WR, Holroyd BR: Characteristics of patients who leave emergency departments without being seen. Acad Emerg Med 2006, 13:848-852.
• [9]Kuan WS, Mahadevan M: Emergency unscheduled returns: can we do better? Singapore Med J 2009, 50:1068-1071.
• [10]Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, McCarthy M, John McConnell K, Pines JM, Rathlev N, et al.: The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med 2009, 16:1-10.
• [11]Holliman CJ, Mulligan TM, Suter RE, Cameron P, Wallis L, Anderson PD, Clem K: The efficacy and value of emergency medicine: a supportive literature review. Int J Emerg Med 2011, 4:44. BioMed Central Full Text
• [12]Goransson KE, Ehnfors M, Fonteyn ME, Ehrenberg A: Thinking strategies used by Registered Nurses during emergency department triage. J Adv Nurs 2008, 61:163-172.
• [13]Widgren BR, Jourak M: Medical Emergency Triage and Treatment System (METTS): A New Protocol in Primary Triage and Secondary Priority Decision in Emergency Medicine. J Emerg Med 2011, 40:623-628.
• [14]Farrokhnia N, Goransson KE: Swedish emergency department triage and interventions for improved patient flows: a national update. Scand J Trauma Resusc Emerg Med 2011, 19:72. BioMed Central Full Text
• [15]Oredsson S, Jonsson H, Rognes J, Lind L, Goransson KE, Ehrenberg A, Asplund K, Castren M, Farrohknia N: A systematic review of triage-related interventions to improve patient flow in emergency departments. Scand J Trauma Resusc Emerg Med 2011, 19:43. BioMed Central Full Text
• [16]Mazzocato P, Savage C, Brommels M, Aronsson H, Thor J: Lean thinking in healthcare: a realist review of the literature. Qual Saf Health Care 2010, 19:376-382.
• [17]Dickson EW, Singh S, Cheung DS, Wyatt CC, Nugent AS: Application of lean manufacturing techniques in the Emergency Department. J Emerg Med 2009, 37:177-182.
• [18]Tragardh B, Lindberg K: Curing a meagre health care system by lean methods–translating 'chains of care' in the Swedish health care sector. Int J Health Plann Manage 2004, 19:383-398.
• [19]Holden RJ: Lean Thinking in emergency departments: a critical review. Ann Emerg Med 2011, 57:265-278.
• [20]Womack JP, Byrne AP, Fiume OJ, Kaplan GS, Touissant J: Going Lean in Health Care. Institute for Healthcare Improvement, Cambridge, MA; 2005.
• [21]Asplund K, Castrén M, Ehrenberg A, Farrokhnia N, Göransson K, Jonsson H, Lind L, Marké LÅ, Norlund A, Oredsson S: Triage och flödesprocesser på akutmottagningen. En systematisk litteraturöversikt. 2010.
• [22]Farrohknia N, Castren M, Ehrenberg A, Lind L, Oredsson S, Jonsson H, Asplund K, Goransson KE: Emergency department triage scales and their components: a systematic review of the scientific evidence. Scand J Trauma Resusc Emerg Med 2011, 19:42. BioMed Central Full Text
• [23]Sibbritt D, Isbister GK, Walker R: Emergency department performance indicators that encompass the patient journey. Qual Manag Health Care 2006, 15:27-38.
• [24]Ravikumar D, Hsia R: Do California counties with lower socioeconomic levels have less access to emergency department care? Acad Emerg Med 2010, 17:508-513.
• [25]Holroyd BR, Bullard MJ, Latoszek K, Gordon D, Allen S, Tam S, Blitz S, Yoon P, Rowe BH: Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial. Acad Emerg Med 2007, 14:702-708.
• [26]Welch S, Augustine J, Camargo CA: Reese C: Emergency department performance measures and benchmarking summit. Acad Emerg Med 2006, 13:1074-1080.
• [27]Dormann H, Diesch K, Ganslandt T, Hahn EG: Numerical parameters and quality indicators in a medical emergency department. Dtsch Arztebl Int 2010, 107:261-267.
• [28]Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA: The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006, 184:208-212.