Implementing wait-time reductions under Ontario government benchmarks (Pay-for-Results): a Cluster Randomized Trial of the Effect of a Physician-Nurse Supplementary Triage Assistance team (MDRNSTAT) on emergency department patient wait times

Abstract

BackgroundInternationally, emergency departments are struggling with crowding and its associated morbidity, mortality, and decreased patient and health-care worker satisfaction. The objective was to evaluate the addition of a MDRNSTAT (Physician (MD)-Nurse (RN) Supplementary Team At Triage) on emergency department patient flow and quality of care.MethodsPragmatic cluster randomized trial. From 131 weekday shifts (8:00–14:30) during a 26-week period, we randomized 65 days (3173 visits) to the intervention cluster with a MDRNSTAT presence, and 66 days (3163 visits) to the nurse-only triage control cluster. The primary outcome was emergency department length-of-stay (EDLOS) for patients managed and discharged only by the emergency department. Secondary outcomes included EDLOS for patients initially seen by the emergency department, and subsequently consulted and admitted, patients reaching government-mandated thresholds, time to initial physician assessment, left-without being seen rate, time to investigation, and measurement of harm.ResultsThe intervention’s median EDLOS for discharged, non-consulted, high acuity patients was 4:05 [95th% CI: 3:58 to 4:15] versus 4:29 [95th% CI: 4:19–4:38] during comparator shifts. The intervention’s median EDLOS for discharged, non-consulted, low acuity patients was 1:55 [95th% CI: 1:48 to 2:05] versus 2:08 [95th% CI: 2:02–2:14]. The intervention’s median physician initial assessment time was 0:55 [95th% CI: 0:53 to 0:58] versus 1:21 [95th% CI: 1:18 to 1:25]. The intervention’s left-without-being-seen rate was 1.5% versus 2.2% for the control (p = 0.06). The MDRNSTAT subgroup analysis resulted in significant decreases in median EDLOS for discharged, non-consulted high (4:01 [95th% CI: 3:43–4:16]) and low acuity patients (1:10 95th% CI: 0:58–1:19]), as well as physician initial assessment time (0:25 [95th% CI: 0:23–0:26]). No patients returned to the emergency department after being discharged by the MDRNSTAT at triage.ConclusionsThe intervention reduced delays and left-without-being-seen rate without increased return visits or jeopardizing urgent care of severely ill patients.Trial registration numberNCT00991471 ClinicalTrials.gov

Cost-effectiveness of a physician-nurse supplementary triage assessment team at an academic tertiary care emergency department

“…29 Most public academic hospitals are supported by public insurance plans with unique funding models; therefore, our results may not be generalizable to other health systems and jurisdictions. However, hospitals using a case-mix, volume-based, fee-for-service, or payfor-performance funding schemes should find this analysis useful.…”

“…29 EDLOS was defined as the duration between triage arrival and departure from the ED. 8 LWBS patients were those who left the ED before a medical exam was initiated.…”

“…The 90th percentile target for physician-initial-assessment (PIA) time was set at 5 hours and 24 minutes, with an ideal target of 3 hours and 48 minutes. 28,29 The duration between triage evaluation and assessment by the doctor was the PIA time. 8 One approach proposed to decrease ED wait-times is the team approach to care [29][30][31][32] or a front-line primary care team.…”

“…28,29 The duration between triage evaluation and assessment by the doctor was the PIA time. 8 One approach proposed to decrease ED wait-times is the team approach to care [29][30][31][32] or a front-line primary care team. A joint report by the major colleges in the United Kingdom recommended senior clinicians be present at the ED front door, 33,34 and some hospitals in Australia 35 and the United States have placed a physician at triage.…”

“…29 This trial took place at Sunnybrook Hospital, a tertiary care academic centre located in Toronto, ON. It is a trauma, regional stroke, interventional cardiology, neurosurgical, and oncology centre with 348 acute care beds.…”