Triage for better care: Upstream regulation of access to emergency department, between healthcare efficiency and a new challenge

Healthcare organisations and governments have invested heavily in electronic health records in anticipation that they will deliver improved health outcomes for consumers and efficiencies across emergency departments. Despite such investment, electronic health records designed to support emergency care have been poorly evaluated. Given the accelerated development and adoption of information technology across healthcare, it is timely that a systematic review of this evidence base is updated in order to drive improvements to design, interoperability and overall clinical utility of electronic health record systems implemented in emergency departments. To assess the impact of electronic health records on healthcare outcomes and efficiencies in the emergency department we carried out a systematic review of published studies on this topic. This is the first review to summarise the cost efficiencies associated with electronic health record use outside of just the United States of America. A systematic search was performed in three scientific databases (MEDLINE, EMcare and EMBASE), of literature published between January 2000 and September 2019. Studies were included in this review if they evaluated electronic health records or health information exchanges (and synonyms for these terms), reported patient outcome and/or healthcare efficiency benefits, were peer-reviewed and published in English. Out of 6635 articles, 23 studies met our inclusion criteria. Wide variation regarding electronic health record access in the emergency department was reported (1.46-56.6%), yet was most frequently reported as less than 20%. Seven different types of health outcomes and three different types of efficiency improvements associated with electronic health record use in the emergency department were identified. The most frequently reported findings were efficiencies, including reductions in diagnostic tests, imaging and costs. This review is the first to report moderate to significant increases in admission rates are associated with electronic health record use in the emergency department, contrasting the findings of previous reviews. Diversity in the methodology employed across the included studies emphasises the need for further research to examine the impact of electronic health record implementation and system design on the findings reported, in order to ensure return on investment for stakeholders and optimised consumer care.

BackgroundEmergency department length of stay is a vital performance indicator for quality and efficiency in healthcare. This research aimed to evaluate the length of stay patterns in emergency departments across Saudi Arabia and to identify predictors for extended stays. The study used secondary data from the Ministry of Health’s Ada’a program.MethodsUsing a retrospective approach, the study examined data from the Ada’a program on emergency department length of stay from September 2019 to December 2021. These data covered 1,572,296 emergency department visits from all regions of Saudi Arabia. Variables analyzed included quality indicators, year of visit, shift time, hospital type, and data entry method. The analysis was conducted using multiple linear regression.ResultsThe study found that the median length of stay was 61 min, with significant differences among related predictors. All associations were significant with a value of p of less than 0.001. Compared to 2019, the length of stay was notably shorter by 28.5% in 2020 and by 44.2% in 2021. Evening and night shifts had a shorter length of stay by 5.9 and 7.8%, respectively, compared to the morning shift. Length of stay was lower in winter, summer, and fall compared to spring. Patients in levels I and II of the Canadian Triage and Acuity Scales had longer stays than those in level III, with those in level I reaching an increase of 20.5% in length of stay. Clustered hospitals had a longer length of stay compared to the non-clustered ones. Pediatric hospitals had a 15.3% shorter stay compared to general hospitals. Hospitals with data entered automatically had a 14.0% longer length of stay than those entered manually. Patients admitted to the hospital had a considerably longer length of stay, which was 54.7% longer compared to non-admitted patients. Deceased patients had a 20.5% longer length of stay than patients discharged alive.ConclusionData at the national level identified several predictors of prolonged emergency department length of stay in Saudi Arabia, including shift time, season, severity level, and hospital type. These results underline the necessity of continuous monitoring and improvement efforts in emergency departments, in line with policy initiatives aiming to enhance patient outcomes in Saudi Arabia.

Health information exchanges (HIEs) are designed to improve the quality and efficiency of healthcare by facilitating improved information sharing between health entities. This study systematically examines the impact of HIE use in emergency departments (EDs) on the quality and efficiency of medical care. We focus on the length of stay (LOS) and the 30-day readmission rate to capture healthcare efficiency and quality, respectively. We also examine whether the breadth of patient health information and physicians’ experience with the HIE moderates these effects. We leverage a unique panel data that tracks actual HIE access by physicians who practice in a set of hospitals that participate in the focal HIE. The patient-level encounter data set—which involves more than 80,000 ED encounters attended by more than 300 physicians over a 19-month period—comprises detailed medical provider information, patient-level medical information, and various other information related to procedures that were performed. After controlling for a battery of patient-specific, physician-specific, disease-specific, and ED visit-specific variables, our results show that HIE access in information-intensive environments (such as EDs) reduces LOS and 30-day readmission rate. We find that breadth of patient health information and physicians’ HIE experience amplify these benefits. We account for endogeneity issues and perform additional falsification tests and robustness checks. We document that benefits of HIE access are amplified for noninjury, chronic condition, and uncommon diagnoses related patient visits. Based on our results, we offer insights to practitioners and academicians alike on how HIEs can yield better patient-level and provider-level outcomes.This paper was accepted by Anandhi Bharadwaj, information systems.Supplemental Material: The web appendix is available at https://doi.org/10.1287/mnsc.2022.4378 .

Background: Crowded emergency departments (EDs) adversely affect patient care and healthcare efficiency, leading to prolonged wait times, delayed treatments, and increased medical errors. This issue also diminishes patient satisfaction and disrupts hospital operations. In Saudi Arabia, ED overcrowding impacts response times and staff morale, highlighting the need for efficient patient flow processes to ensure timely and effective care. Objectives: The aim of this study is to identify the main bottlenecks in the workflow of Saudi Arabian EDs from patient arrival to disposition. Design: A retrospective quantitative study analyzed data from 753 patients across multiple hospitals in Saudi Arabia's EDs to identify workflow bottlenecks. Using SPSS and AMOS for data analysis, various statistical methods, including ANOVA and structural equation modeling (SEM), were employed to evaluate key performance metrics and their influence on the total length of stay (LOS). Results: The Doctor to Decision Time is the most significant bottleneck, followed by the Triage to Doctor Time. CTAS3 and CTAS4 categories experience the most significant delays across multiple stages. In addition, the default model in AMOS 29 shows an excellent fit, indicating that reducing delays in Decision to Disposition Time (estimate = 0.840) and Doctor to Decision Time (estimate = 0.442) is crucial for improving the total LOS in the ED. Conclusion: This study identifies significant inefficiencies in the ED workflow in Saudi Arabia, particularly in the Doctor to Decision Time and Triage to Doctor Time stages, and recommends streamlining consultation protocols, enhancing medication delivery, expediting lab and radiology services, and increasing staffing to improve operational efficiency and patient outcomes. Faster bed turnover reduces Decision to Disposition Time and frees up ED beds. Adequate staffing improves triage, evaluation times, and care quality. Well-trained nurses enhance patient interactions and reduce delays. Standardized guidelines ensure timely treatment. Effective communication and teamwork improve patient flow and reduce bottlenecks.

ABSTRACTAim(s)To analyse the dimensions of the omission of nursing care in emergency departments, including its attributes, antecedents, and consequences, using Walker & Avant's concept analysis method.Design Concept AnalysisMethods: Walker and Avant's eight‐step method defined attributes, antecedents, and consequences of the omission of nursing care in emergency departments.Data SourcesA comprehensive literature review was conducted using CINAHL, MEDLINE, Embase, Health Management Database, and Cochrane Library, covering publications from 2001 to 2024. The search was conducted in August 2024.ResultsKey attributes were delayed, incomplete, or interrupted care, mostly due to insufficient staffing or unpredictable patient volumes. Antecedents included high workloads, inadequate skill mixes, and understaffing. Consequences were increased patient morbidity and mortality, nurse burnout, and job dissatisfaction. A research gap exists in paediatric‐specific measurement tools.ConclusionIdentifying dimensions of omitted nursing care in emergency departments informs interventions to improve patient safety and care quality. Developing paediatric‐specific measurement tools is essential.Implications for the Profession and/or Patient CareThe findings emphasise the need for improved staffing and resource allocation policies, reducing risks to patients and enhancing nurse satisfaction.ImpactThis study addressed the gap in understanding omitted nursing care specifically in emergency departments. Findings highlight systemic issues impacting patient outcomes and nurse well‐being. The results will guide organisational improvements and future research globally.Reporting MethodThis study adhered to EQUATOR guidelines, following Walker and Avant's method for concept analysis.Patient or Public ContributionThis study did not include patient or public involvement.Impact StatementThis study underscores the critical impact of the omission of nursing care (ONC) in emergency departments (EDs) on patient safety, nurse well‐being, and healthcare efficiency. ONC contributes to increased morbidity, mortality, and adverse events, highlighting the urgent need for improved staffing models and resource allocation. Training programmes should equip emergency nurses with prioritisation strategies to mitigate care omissions. Policymakers must recognise ONC as a key quality indicator, ensuring adequate workforce support. Additionally, this study identifies a gap in measuring ONC in paediatric EDs, calling for the development of tailored assessment tools and further research on intervention strategies.

Overcrowding in emergency departments (EDs), particularly pediatric emergency departments (PEDs), remains a significant challenge that affects patient outcomes and the efficiency of healthcare. Rapid diagnostic tests (RDTs) for respiratory viruses could be a promising tool for improving patient management by enabling prompt etiological diagnoses. This study investigated whether positive RDT results for influenza or adenovirus were associated with differences in length of stay (LOS) in a tertiary PED during epidemic seasons. A retrospective cohort study was conducted at IRCCS Istituto Giannina Gaslini, Genoa, Italy, over two epidemic seasons (December-February, 2023-2025). All consecutive pediatric patients presenting with fever and respiratory symptoms who underwent rapid diagnostic testing for influenza and/or adenovirus during two epidemic seasons were included. LOS was assessed as the time from triage to discharge (TTD) and from physician assignment to discharge (ATD). Patients were stratified by positive versus negative RDT results. Analyses between groups used the Mann-Whitney U-test for continuous variables and chi-square or Fisher's exact test for categorical variables. A two-tailed p-value < 0.05 was considered significant. Of the 1238 patients analyzed, the median age was 3.3 years (IQR 1.4-7.2), with male predominance (58.1%). A total of 330 patients (26.6%) tested positive. Compared with negative results, positive RDTs were associated with shorter median TTD (217.0 vs. 239.0 min, p < 0.001) and ATD (66.0 vs. 148.5 min, p < 0.001), which was consistent in both the influenza and adenovirus subgroups. No significant difference in 72 h readmission rates was observed between groups. Among children tested with RDTs for influenza and adenovirus, positive results were associated with reduced PED LOS without increasing early return visits. While these findings suggest a potential role in supporting patient flow, conclusions regarding the broader impact on PED overcrowding should be drawn with caution. Further prospective studies, including non-tested controls and additional viral targets, are required.

A predictive approach for myocardial infarction risk assessment using machine learning and big clinical data

Efficiency is an important value for all publicly funded healthcare systems. Limited resources need to be used prudently and wisely in order to ensure best possible outcomes and waste avoidance. Since 2010, the drive for efficiency, in the UK, has acquired a new impetus, as the country embarked on an ‘age of austerity’ purportedly to balance its books and reduce national deficit. Although the NHS did not suffer any direct budget cuts, the austerity policies imposed on the welfare system, including social and mental healthcare, have had a direct and detrimental impact on the healthcare service. This paper draws from a qualitative study conducted in three A&E Departments in England to explore the effects of austerity policies on the everyday experiences of doctors and nurses working in Emergency Departments. It discusses the operationalisation of efficiency in A&E, in a climate of austerity, and its effects on the experiences and practices of healthcare professionals. It uses the empirical data as a springboard to highlight the role of structures and regulations, in this case targets and protocols, in how core healthcare ethical values, such as empathy, are exercised in practice. It provides an analysis of the normative role structures and regulations can play on the perception and practice of professional duties and obligations in healthcare.

Background Emergency departments (EDs) are vital access points for individuals with acute health issues and vulnerable groups affected by social determinants such as homelessness, poverty, domestic violence, substance use, and mental health disorders. Social workers are crucial in addressing these factors and enhancing healthcare efficiency. However, evidence on their effectiveness in EDs remains limited. This study retrospectively evaluates the impact of social work interventions on patient outcomes and healthcare utilization. Methods We conducted a retrospective cohort study among patients aged ≥18 years consulted to the social work unit at Ankara Bilkent City Hospital ED between February 2019 and February 2024. Data from electronic records, social work assessments, and follow-up systems were analyzed. Demographic and clinical data, consultation reasons, interventions, and outcomes were assessed. Descriptive statistics and Chi-square tests were used (p &amp;lt; 0.05). Results A total of 714 patients were included (48.0% male; median age: 56 years). Main consultation reasons were housing needs (24.9%), domestic violence and sexual abuse (11.1%), substance use (2.7%), and psychosocial issues (28.0%). Interventions included psychosocial support (40.8%), resource referral (24.4%), crisis intervention (25.1%), and family contact (25.1%). Patients receiving interventions had lower hospitalization rates and more organized discharges (p &amp;lt; 0.05). Incomplete assessments were more frequent during night shifts (p &amp;lt; 0.001). Conclusions Social work interventions in EDs enhance patient care quality and optimize healthcare utilization, particularly in managing housing instability, violence, psychosocial issues, and addiction. Strengthening 24-hour coverage, multidisciplinary integration, and standardized models are key strategies for improving outcomes. Further research is needed to evaluate long-term effects. Key messages • Social work interventions improve emergency department care quality and healthcare efficiency. • Expanding 24-hour social work services and integration enhances patient outcomes.

To examine the distribution and frequency of International Classification of Diseases, 10th Revision (ICD-10), codes in emergency departments (EDs) across Malaysia, providing insights into the most common diagnoses. The aim is to support the development of a principal diagnosis short list for implementing ED-specific diagnosis-related groups (DRGs) to enhance resource allocation and healthcare efficiency. A cross-sectional study conducted as part of a functional exercise by the Ministry of Health Malaysia, with systematic retrospective data collection over a 6-week period in 2022. 13 public emergency hospitals across Malaysia, representing state, major specialist, minor specialist and non-specialist hospitals, including facilities from Sabah and Sarawak for geographical diversity. 10 247 ED visit records were collected through systematic random sampling, of which 9942 complete and valid records were retained for analysis after the exclusion of incomplete or erroneous entries. The study included 9942 ED patient records from 13 public hospitals across Malaysia over a 6-week period. Of these, 54.4% were male, and 45.5% were female. Malaysian citizens comprised 96.1% of the study population. The most frequently reported diagnoses were respiratory diseases (21.2%), followed by injuries and poisoning (13.2%) and digestive system disorders (8.4%). A total of 946 unique ICD-10 codes were identified, with 73.7% used fewer than five times. The top 20 diagnoses accounted for 42.9% of all records. Acute upper respiratory infection (J06.9) was the most commonly reported diagnosis (961 cases), followed by COVID-19 (U07.1, 608 cases) and gastroenteritis of unspecified origin (A09.9, 313 cases). The data demonstrated variation in the distribution of ICD-10 diagnoses across participating hospitals, highlighting key diagnostic categories relevant for future DRG development. This study highlights the diversity of diagnoses in Malaysian EDs and underscores the need for tailored DRGs to optimise healthcare resource allocation. The findings suggest that a principal diagnosis short list may support future efforts to improve classification consistency and inform resource planning, although its effect warrants empirical evaluation. Given the concentration of diagnoses within a limited number of ICD-10 codes, implementing DRGs in emergency care is both feasible and necessary. Future research should expand data collection to capture seasonal trends and refine the principal diagnosis list to further support DRG categorisation and ensure its applicability across varying healthcare demands.

Telemedicine has been shown to improve patient access to medical care while potentially improving overall healthcare efficiency. It has not been consistently explored on an acute care surgery service as a method of increasing clinic availability and efficiency within a safety-net hospital system. Socioeconomic hardships associated with an in-person clinic visit can deter patients with limited resources. A virtual clinic for post-operative laparoscopic cholecystectomy patients was developed. We hypothesized that a virtual follow-up increases clinic efficiency and availability for new patients without compromising patient safety. A retrospective review of patient and clinic outcomes before and after implementing virtual post-op visits for uncomplicated laparoscopic cholecystectomy patients on an acute care surgery service was performed. Providers called post-operative patients using a standardized questionnaire. Data included outpatient clinic composition (new vs. post-operative patients), elective operations scheduled, emergency department visits, and loss to follow-up rates. February to March 2017 was the baseline pre-intervention period, while February to March 2019 was post-intervention. Pre-intervention clinics consisted of 17% new and 50% post-op visits, in comparison to 31% new and 27% post-op visits in the post-intervention group (p < 0.01). Elective operations scheduled increased slightly from 8.4 to 11.5 per 100 patient visits, but was not statistically significant (p = 0.09). There was no change in the number of post-operative patients returning to the emergency department (p = 0.91) or loss to follow-up (p = 0.30) rates. Through the implementation of virtual post-operative visits for laparoscopic cholecystectomy patients, clinic efficiency improved by increasing new patient encounters, decreasing post-operative volume, and trending towards increased operations scheduled. This change did not compromise patient safety. Further implementation of telemedicine on an acute care surgery service is a promising method to expand services offered to an at-risk population and increase efficiency in a resource-limited environment.

Head trauma was the significant public health issue and a common cause of emergency department visits. Cranial computed tomography (CT) was widely used in its evaluation; however, overuse-particularly in mild cases-raises concerns about patient safety and healthcare efficiency. This study aimed to evaluate the appropriateness of cranial CT use in head trauma patients, its relationship with Glasgow Coma Scale (GCS) scores, and the prevalence of potentially avoidable imaging. This retrospective study included 1,000 patients presenting with head trauma, who underwent cranial CT. Data collected included demographics, trauma mechanism, GCS score, CT findings, and indication for imaging. CT necessity was assessed using the Canadian CT Head Rule and New Orleans Criteria. CTs performed in patients with GCS 13-15, normal findings, and no guideline-based indications were classified as potentially avoidable. Of all patients, 65% were male, with a mean age of 42.1 ± 20.7 years. Mild trauma (GCS 13-15) was present in 77.5% of cases. Intracranial pathology was detected in 35.9% overall, with higher rates in patients with moderate and severe trauma. Unnecessary CT imaging was found in 57% of all cases, and in 80.2% of mild trauma cases. A statistically significant association was found between lower GCS scores and intracranial findings (P < 0.001). Cranial CT was often overused in mild head trauma without adherence to clinical guidelines. Promoting the use of decision support tools and raising awareness among clinicians and patients are crucial for reducing potentially avoidable imaging, radiation exposure, and healthcare burden.

AimsThis presentation describes how to integrate physician assistants (PAs) into a regional public hospital emergency department (ED) in Queensland, and the impact of PAs on patient care, healthcare efficiency, and...

Background: There is a growing need for the expansion of the scope of practice in healthcare professionals worldwide. Canadian provinces such as Ontario, have piloted community-based projects involving the introduction of remote healthcare monitoring services. In August 2022, the Community Paramedicine Remote Care Monitoring (CPRPM) Program was launched in a relatively rural county – Oxford County, Ontario – by the community paramedic program in partnership with the Oxford Ontario Health Team (OHT). Objectives: To evaluate the performance of the CPRPM program during the first eight months of its launch with regards to; a) improving patient outcomes, b) reducing hospital emergency department (ED) visits or 911-call frequency, and c) enhancing overall healthcare efficiency. Intervention: This paper describes the impact of the CPRPM program through an interim performance evaluation report. The program was launched for residents at high risk of hospitalization due to exacerbations related to congestive heart failure, coronary obstructive pulmonary disease, diabetes, hypertension, or who frequently contacted 911-calls for ED visits in the past year. Referrals of patients were through the Emergency Medical Services 911-calls data and health care providers. Patients in this 90-day program were provided self-management education and medical kits for chronic disease monitoring. The program also included in-person visits and 24/7 availability by the paramedics. Patients participated in monthly Experience Surveys. There are three domains of impact discussed in this evaluation report, which are the impact of the CPRPM program on 1) 911 activations, 2) ED visits, and 3) patient satisfaction. The pre-post design was used to compare between the average 911 activations and ED visits before and after program implementation. The paired t-test analysis was used for statistical analysis. Results: There were 133 patients enrolled in the CPRPM program between August 2022 and March 2023, 53% of which were female. The average age was 77 and ranged from 22 to 98 years. Preliminary findings show a potential positive effect of the program in the reduction of number of 911-call activation and ED visits. Patients were mainly satisfied or very satisfied with the CPRPM program experience (96%). The analysis is in progress and the findings will be presented for the conference in April. Conclusion: This pilot program is unique in remotely monitoring patients at high risk of hospitalization in Oxford, Ontario; a relatively low population density county in Ontario, Canada. Early evidence suggests that this novel program is having the intended impact in efficiently enhancing the reduction of complications and potentially preventing medical emergencies. Impact: This program helps in integrating and expanding the workforce scope of practice of paramedics in healthcare. It empowers patients as partners in adhering to treatment plans and leading healthier lifestyles. Finally, it improves accessibility and enhances healthcare equity by helping populations in need regardless of rurality of residence.

The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis