SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
October, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
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
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
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.
| 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.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
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
Physician-led triage versus nurse-led triage |
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| People Patients consulting emergency departments (ED) Settings Emergency departments Intervention Physician-led triage Comparison Nurse-led triage |
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| Outcomes | Absolute effect (95% CI) | Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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| Nurse-led triage |
Physician-led triage |
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| ED Length of stay |
Median time: 187 minutes |
37 minutes less (23 to 51 less) |
17% less (12 to 27% less) |
Moderate |
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| Physician initial assessment time |
32 minutes |
3o minutes less (3 to 57 less) |
94% less (3 to 100% less) |
Moderate |
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| Patients leaving without being seen |
67 per 1000 |
54 per 1000 (46 to 65) |
RR 0.82 (0.67 to 1.00) |
Moderate |
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| Patients leaving the ED against medical advice |
0.69% |
0.63% |
RR 1.10% |
Low |
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| CI: Confidence interval; RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see explanations) | ||||||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
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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
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| EQUITY | |
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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 | |
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| MONITORING & EVALUATION | |
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*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 |
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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
This summary has been peer reviewed by: Katherine Harding and Brian Rowe.
Ciapponi A, Does physician-led triage reduce emergency department overcrowding? A SUPPORT Summary of a systematic review. October 2016. www.supportsummaries.org
