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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
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
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2012 (English)In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 20, no 1, 57- p.Article in journal (Refereed) Published
Abstract [en]

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 160,684 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.

Place, publisher, year, edition, pages
2012. Vol. 20, no 1, 57- p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-181961DOI: 10.1186/1757-7241-20-57ISI: 000310207200001PubMedID: 22905993OAI: oai:DiVA.org:uu-181961DiVA: diva2:558184
Available from: 2012-10-02 Created: 2012-10-02 Last updated: 2017-12-07Bibliographically approved
In thesis
1. Patient Safety in the Emergency Department: Culture, Waiting, and Outcomes of Efficiency and Quality
Open this publication in new window or tab >>Patient Safety in the Emergency Department: Culture, Waiting, and Outcomes of Efficiency and Quality
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of this thesis was to investigate patient safety in the emergency department (ED) and to determine whether this varies according to patient safety culture, waiting, and outcomes of efficiency and quality variables.

I: Patient safety culture was described in the EDs of two different hospitals before and after a quality improvement project. The questionnaire “Hospital Survey on Patient Safety Culture” was used to investigate the patient safety culture. The main finding was that the staff at both hospitals scored more positively in the dimension Team-work within hospital after implementing a new work model aimed at improving patient flow and patient safety in the ED. Otherwise, we found only modest improvements.

II: Grounded theory was used to explore what happens in the ED from the staff perspective. Their main concern was reducing patients’ non-acceptable waiting time. Management of waiting was improved either by increasing the throughput of patient flow by structure pushing and by shuffling patients, or by changing the experience of waiting by calming patients and by feinting to cover up.

III: Three Swedish EDs with different triage models were compared in terms of efficiency and quality. 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. Quality indicators (i.e., patients leaving before treatment was completed, the rate of unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days) improved under the physician-led team triage.

IV: Efficiency and quality variables were compared from before (2008) to after (2012) a reorganization with a shift of triage model at a single ED. Time from registration to physician decreased by 47 minutes, and the length of stay decreased by 34 minutes. Several quality measures differed between the two years, in favour of 2012. Patients leaving before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days all improved despite the reduced admission rate.

In conclusion, the studies underscore the need to improve patient safety in the ED. It is important to the patient safety culture to reduce patient waiting because it dynamically affects both patients and staff. Physician-led team triage may be a suitable model for reducing patient waiting time and increasing patient safety.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2014. 100 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1009
Keyword
Emergency department, physician, triage, teamwork, HSOPS, grounded theory, waiting, patient safety, culture
National Category
Other Medical Sciences not elsewhere specified
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-223987 (URN)978-91-554-8971-7 (ISBN)
Public defence
2014-08-29, Aulan, Ingång 21, Västmanlands sjukhus, Västerås, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2014-05-28 Created: 2014-04-29 Last updated: 2014-06-30Bibliographically approved

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Burström, LenaWiklund, TonyEngström, Marie-LouiseEnlund, Mats

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