October, 2016 - SUPPORT Summary of a systematic review | print this article |

Does physician-led triage reduce emergency department overcrowding?

Emergency department overcrowding is a serious problem facing healthcare systems worldwide that can lead to delays in time-sensitive diagnostic and treatment decisions and poor health outcomes. Triage systems are used to decide who needs urgent care and who can wait, sorting patients according to urgency or type of service required. They employ systems to prioritise or assign patients to treatment categories in order to assist in their management.

 

Key messages

 

  • Physician-led triage compared to nurse-led triage probably reduces emergency department length of stay, physician’s initial assessment time, and the proportion of patients leaving without being seen.
  • It may lead to little or no difference in the proportion of patients leaving the emergency department against medical advice.
  • None of the included studies were conducted in a low-income country.

 

Background

Triage or prioritisation is defined as any system that either ranks patients in order of priority, or sorts patients into the most appropriate service. Triage processes are often used by emergency departments, but may also be used in a broad spectrum of other health services. Triage or prioritisation systems, based on acuity and risk are intended to facilitate decisions about allocation of resources, ensure that patients with the most urgent needs get the most timely service, and ensure an appropriate type and intensity of care. Most triage systems are based on physicians with or without participation of nurses.

 



About the systematic review underlying this summary

Review objectives: To estimate the effectiveness of physician-led triage in reducing emergency department (ED) overcrowding.
Type of What the review authors searched for What the review authors found
Study designs & interventions Parallel or cluster randomized trials, non-randomized trials, cohort studies, interrupted time series studies, case-control studies, and before-after studies assessing the effect of physician-led triage systems
28 included studies: 2 randomized trials, 7 non-randomized trials, 1 interrupted time series study, 16 before-after studies, and 2 prospective cohort studies. The studies compared nurse-led triage with triage teams (20 studies) or emergency physicians (8).
Participants Adult or mixed (children and adult) patients seeking healthcare
All studies were conducted in single emergency departments
Settings Emergency departments
USA (17), UK (4), Australia (2), Canada (2), Hong Kong (2), Singapore (1)
Outcomes ED length of stay, time from patient arrival ⁄ triage to physically leaving the ED, physician initial assessment time from patient arrival, proportion of patients leaving the ED without being seen and leaving the ED against medical advice
ED length of stay (19), physician initial assessment time from patient arrival (9), proportion of patients leaving the ED without being seen (12) and leaving the ED against medical advice (2)
Date of most recent search: May 2009
Limitations: This is a well-conducted systematic review with only minor limitations, but the last search was conducted in 2009.

Rowe BH, Guo X, Villa-Roel C, et al. The role of triage liaison physicians on mitigating overcrowding in emergency departments: a systematic review. Acad Emerg Med 2011; 18:111-20.

Rowe BH, Guo X, Villa-Roel C, et al. The role of triage liaison physicians on mitigating overcrowding in emergency departments: a systematic review. Acad Emerg Med 2011; 18:111-20.

Summary of findings

28 studies were included with data collected from over 400,000 patients across all of the studies reporting sample size.

Physician-led triage compared to nurse-led triage probably reduces

  • Emergency department length of stay,
  • Physician initial assessment time, and
  • The proportion of patients leaving without being seen.
  • The certainty of this evidence is moderate.
  • Physician-led triage compared to nurse-led triage may lead to little or no difference in the proportion of patients leaving the emergency department against medical advice. The certainty of this evidence is low.

Physician-led triage versus nurse-led triage

People            Patients consulting emergency departments (ED)
Settings          Emergency departments
Intervention   Physician-led triage
Comparison    Nurse-led triage
Outcomes Absolute effect (95% CI) Relative effect
(95% CI)
Certainty of the evidence
(GRADE)
Nurse-led triage
Physician-led triage
ED Length of stay
 Median time: 187 minutes 

37 minutes less

(23 to 51 less)

17% less

(12 to 27% less)

Moderate

Physician initial assessment time
32 minutes 

3o minutes less

(3 to 57 less)

94% less

(3 to 100% less)

Moderate

Patients leaving without being seen
67 per 1000

54 per 1000

(46 to 65)

RR 0.82

(0.67 to 1.00)

Moderate

Patients leaving the ED against medical advice
0.69%
0.63%

RR 1.10%

Low

CI: Confidence interval; RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see explanations)

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
  • None of the included studies were conducted in a low-income country.

When assessing the transferability of these findings to low-income countries the following factors should be considered:

− The availability of human resources

− Basic infrastructure

− The acceptability and costs of the triage systems

 


EQUITY
  • There was no information in the included studies regarding the differential effects of the interventions on resource-disadvantaged populations.
Resources needed for triage may be less available in disadvantaged settings. Triage systems may increase inequity if they are not available to these populations.
ECONOMIC CONSIDERATIONS
  • The systematic review did not address economic considerations.

 

  • While triage systems may increase capacity, scaling up triage may require additional resources.
  • Local costings should be undertaken, in settings differing from the original investigations.
MONITORING & EVALUATION
  • There is moderate certainty evidence that physician-led triage probably reduces the time taken to see patients and patients leaving without being seen, but the optimal process for triage is unknown.

 

  • Larger and more rigorous studies are required to determine the effects and the cost-effectiveness of triage particularly in resource-poor settings.
  • The studies should provide details about the process, the context, and the patients.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods



 

Additional information

Related literature

These systematic reviews also addressed triage systems:

 

Harding KE, Taylor NF, Leggat SG. Do triage systems in healthcare improve patient flow? A systematic review of the literature. Australian Health Review 2011; 35:371-83.

 

Oredsson S, Jonsson H, Rognes J, et al. A systematic review of triage-related interventions to improve patient flow in emergency departments. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011; 19:43.

 

Broadbent M, Creaton A, Moxham L, Dwyer T. Review of triage reform: the case for national consensus on a single triage scale for clients with a mental illness in Australian emergency departments. Journal of Clinical Nursing 2010; 19:712-5.

 

Bond K, Ospina M, Blitz S, et al. Interventions to reduce overcrowding in Emergency Departments. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health, 2006.

 

Cooke M, Fisher J, Dale J, et al. Reducing attendances and waits in emergency departments: a systematic review of present innovations. Warwick, UK: National Co-ordinating Centre for NHS Service Delivery and Organisation, 2005.

 

Bruijns SR, Wallis LA, Burch VC. Effect of introduction of nurse triage on waiting times in a South African emergency department. Emerg Med J 2008;25:395–397.

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Katherine Harding and Brian Rowe.

 

The summary should be cited as

Ciapponi A, Does physician-led triage reduce emergency department overcrowding? A SUPPORT Summary of a systematic review. October 2016. www.supportsummaries.org



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