LO67: A variation on Triage Liaison Physicians (TLP): a comparative analysis of the Emergency Department Disposition and Care Consultant (EDC) concept

Abstract

Introduction: Despite evidence that triage liaison physicians (TLP) effectively reduce emergency department (ED) overcrowding, support for these interventions is patchy. The aim of this study was to evaluate the implementation of a TLP-like ED Disposition and Care Consultant (EDC) shift at an academic tertiary care ED. Methods: A 24-week pilot project was conducted 11/16-04/17. Physicians worked 8- hour day (07-15:00) and/or evening (15:00-23:00) EDC shifts and performed immediate triage and patient care when needed, assisted triage RNs, answered all incoming calls, and managed administrative matters. Due to their voluntary nature, not all shifts were filled. This study compared active (EDC) and control (C) shifts on the following ED metrics: length of stay (LOS), proportions of patients who left without being seen (LWBS), and safety (return visits to ED). Descriptive (median and interquartile range {IQR} and proportions) and simple (Wilcoxson-Mann-Whitney, chi-square, z-proportion) tests are presented for continuous and dichotomous outcomes, respectively. Multiple linear regression identified factors associated with LOS. Results: Of 112 possible EDC shifts, 58 (52%) were filled involving 4289 patients and compared to 276 C shifts involving 21,358 patients. ED volume, patient age (49; IQR: 31, 66), mode of arrival (~30% EMS), triage levels (~51% level 3), and complaints were similar between the groups. Overall, the EDC group reduced LWBS by 16% (8.7% vs. 10.4%; p=0.001), ED LOS for discharged patients by 30 minutes (5.5 vs. 6.0 hours; p<0.001), and ED LOS for admitted patients by 42 minutes (9.7 vs. 10.4 hours; p=0.02). The EDC increased the proportion discharged <4 hours by 28% (20.1 vs. 15.7%; p<0.001) and increased the proportion admitted <8 hours by 17% (8.2% vs. 9.6%, p=0.002). ED relapses <72 hours were similar (9.3% vs. 8.9%; p=0.4); however, admissions were higher in the EDC shifts (25.3% vs. 23.8%; p=0.04). In addition to EDC coverage status, LOS was influenced by triage level (1.7%, p<0.001), disposition (19.6%, p<0.001), and age (4.8%, p<0.001). Conclusion: Our results indicate that an EDC shift, while unpopular with many physicians, provides valuable services to an overcrowded ED and that the implementation of this type of shift could reduce LOS and LWBS statistics in a tertiary care institution. Additional evaluations to examine this and other front-end interventions in other ED centers are indicated.