Upload
trinhduong
View
217
Download
0
Embed Size (px)
Citation preview
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