LO29: Interventions at triage to improve emergency department throughput: a systematic review

Abstract

Introduction: Emergency Department (ED) crowding is the primary threat to emergency care quality. Input and outflow factors are important factors, but EDs must optimize throughput efficiency by improving internal processes from triage to disposition, and triage is the first throughput phase. Triage throughput interventions exclude strategies that direct patients away from the ED (these modify input rather than throughput). Previous research has described physicians in triage, team triage, telemedical triage, and nurse practitioner (NP) or physician assistant (PA) led triage, but their impact has never been systematically evaluated. Methods: We conducted systematic database searches in Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials without the use of filters or language restrictions of all triage interventions that effected ED throughput (PROSPERO:CRD42019125651). Two independent reviewers screened studies. Study quality was assessed using the Cochrane Risk of Bias tool (version 2) for randomized controlled trials, and the National Heart, Lung, and Blood Institute quality assessment tool for other designs. Results: 18 studies met inclusion criteria (Cohen's k = 0.69). Study results were not pooled due to high statistical heterogeneity as assessed by chi-squared and I-squared statistics. Studies were grouped into physician led, NP or PA led, and team triage interventions. Six physician in triage interventions reported LOS changes between -82 and + 18 minutes. Five NP/PA led triage interventions resulted in LOS changes of -106 to + 19 minutes. Five team triage interventions reported LOS reductions of 4 to 34 minutes. One telemedicine triage study reported a non-significant 8 minute increase in LOS. Six physician at triage interventions yielded significant LWBS rate improvement (relative risk {RR}= 0.29-0.82). Team triage interventions generated LWBS rate changes ranging from meaningful improvement (RR = 0.58) to substantial deterioration (RR = 1.68). Five studies have low risk of bias, 11 studies have some risk of bias, and 2 studies have high risk of bias (Cohen's kappa = 0.58). Conclusion: Fourteen of 18 triage interventions reduced EDLOS and/or LWBS rate. Physician, NP and PA led triage were the most effective triage interventions. To aid widespread adoption, future research should focus on interrupted time series or RCT designs, and more comprehensive descriptions of the contextual factors affecting implementation of these interventions.