Emergency Room Efficiency Improving Literature Review Chapter

Pages: 25 (11016 words)  ·  Bibliography Sources: ≈ 51  ·  File: .docx  ·  Level: Master's  ·  Topic: Healthcare

It was suggested that none of the scales be used as sole criteria for assigning patients to the lowest triage levels. The most common complaint about triage scales is whether the selected vital signs are most representative of the various risk groups. This suggests that development of better scales is not the answer to improving accuracy and assigning triage categories. Relying on scales without the introduction of the human factor is dangerous. The most significant finding of this study in regards to the present research is that nothing can replace the human factor when it comes to assigning triage categories, regardless of the scale or method used. Scales can be an important tool in the decision-making process, but the decision should not rely entirely on the triage scale. This highlights the importance of having qualified staff in the triage area. Scales cannot account for differentiation in the medical history or tolerance of individual patients. Much of the information gathered at triage is visual, as well as highly subjective. Scales would be useful if patients were more homogeneous, but they are not, which makes the human side of the assessment even more important than the scale. Scales can serve as guidelines, but that is the extent of their usefulness.

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Taboulet, Moreira, Hass and associates (2009) examined the FRENCH triage tool for patients visiting the emergency room. The scale is based on 100 determining factors including complaints, vital signs, and vital parameters. It is a 5-level scale that is gaining popularity. Results of this study indicate that in a blind study with respect to the original triage, nurses that re-triaged patients over 14 day found that this scale was a reliable and valid method for assessing the triage level of patients. It is not known if the study suffers from the same difficulties addressed in the comparative study of various assessment instruments discussed earlier. The author considered the results of the study conclusive. However taking a majority of the research located during this literature review into consideration, the reliability and validity of any instrument as a sole means of triage must be questioned.

Literature Review Chapter on Emergency Room Efficiency Improving Emergency Assignment

Tworney, Wallis, & Myers (2007) found many inconsistencies in methods used for evaluating various triage scales. It was found that differences exist in validation methods between developed countries and developing countries. It supported the need for consensus building in the valuation approach to assessing triage scales. This study examined the development of a new scale that could be used in a developing country situation. The Delphi method was examined as a way to validate triage scales in developing nations.

Jensen (2009) suggested utilizing a system such as Lean Management, Six Sigma, Total Quality Management, or Statistical Process Control to improve patient flows in emergency rooms. To achieve successful implementation of the strategies, an analysis of personnel by department and function must be conducted. This study suggests that standard quality improvement protocols may help to reduce wait times and improve arrival to physical times, when used in conjunction with standard triage methods. At this point, this concept has not been studied.

Improving patient flow times and reducing emergency department wait times is not just a problem that plagues hospitals in the United States. Swedish hospitals have placed this topic as a priority and as a result many current research studies originate from Swedish hospitals. For instance, Farrokhnia & Goransson (2011) explored emergency wait times and patient flow processes in Swedish emergency departments. The study used a survey to obtain its results. This study found that the most common practice in Swedish triage departments was the employment of a triage scale. The triage scale triage method was widely implemented across the country. Flow-related interventions were not as common.

Many Swedish hospitals indicated that they plan to implement nurse requested X-ray systems to improve patient flow and to get doctors the information that they need quicker. This will help to improve the time between arrival and final disposition of the patient. This study failed to address the effect that the triage scales had on improving patient wait times. It is not known if the triage scale method was effective, or if they harmed patient quality and service. Nonetheless, the scales are widely used in Sweden as a means to assess patients when they arrive at the emergency department.

Murrell, Offerman, & Kauffman (2011) studied the application of lean principles to develop a Rapid Triage and Treatment (RTT) system that did not include being seen by a physician. The objective of the study was to determine if the RTT system would result in reduced wait times without employing the use of a Physician. Numerous studies throughout this literature review explored the affect of having a physician in the triage area. They explored how physicians in triage affected emergency department wait times and patient flow throughout the entire hospital system. A majority of the studies concluded that having a physician in the triage significantly improved wait times from the time and patients came through the door until they were seen by a doctor and processed throughout the hospital. The physician in triage method was found to be superior to the RTT system in this respect.

Physicians in Triage

A study by Han, France, & Levin et al., (2010) examined the effects of placing a Physician in triage for 8-hour shifts in the afternoon seven days of the week. An additional Physician was placed in triage so that evaluation and treatment could begin in the waiting area. The hospital information system was used to obtain patient data, and waiting room statistics. A nine-week period the prior to the study was used as a control for the study. Each phase of the study occurred for nine weeks at a time. It was found that overall emergency department length of stay decreased by 11 minutes when a physician was in triage, but that this decrease was attributed to patients that were not admitted. No difference was found in patients that were admitted. However, perhaps the greatest affect of the intervention was a decrease in LW BS rates. LWBS 4.5% to 2.5%. Time spent on ambulance diversion decreased from 5.6 days per month to 3.2 days for month. The study found that total time spent in the emergency room was negligible, but the effects of having a physician in triage improved other quality factors of the emergency department.

SoRelle (2011) found that less than half of high-acuity patients in an urban emergency room setting completed triage in 10 minutes or less. The standard of 10 minutes or less is recommended by the five-tier Emergency Severity Index. This index is a common method of triage used in many hospital settings. The average time from arrival to triage completion was 12.3 minutes with a range of 0 minutes to 128 minutes. Obviously, the 128 minutes is completely unacceptable. Those who completed triage in 0 minutes represented patients that were obviously an acute distress. The sample consisted of 3,932 high acuity patients, 63 of whom fell into index category 1, which consists of those needing the highest level of immediate treatment. The remainder fell into index 2. The study only included patients that were walk-ins and excluded those that arrived by ambulance. Of the total sample population 27% were taken immediately to a room and 41% completed triage within the 10 minute time frame allowed. Triage was over 20 minutes for 25% of patients and over 30 minutes for 10%.

Longer triage times were associated with index 2 patients. It was found that fewer met the higher severity index arrived between 10:00 AM and 10:00 PM at that particular hospital. It is not known if this pattern is widely applicable to other hospital settings or if it is unique to this particular sample population. Finding ways to improve triage times is a priority for patients that fall into the most severe categories. This study establishes the need for developing better methods for faster triage, not only at the hospital used in this study, but it every hospital around the world.

Russ, Jones, & Aronsky, (2010) conducted a study that coincides with that of SoRelle (2011). This study took place in a longer time frame than that of the previous study, using a 23-month study period. It involved a larger sample population of 66,909 patients. It only included those that were sent to the waiting room after triage, but that eventually spent time in a bed in the emergency room. It did not distinguish those that were later admitted from those that were sent home after treatment in the emergency department. Of these patients, nearly 23% had orders placed by a Physician in the triage area. A matched comparison was performed with patients with orders placed via the standard triage system. Those with orders placed using the standard triage system had an average weight of 37 minutes. When a Physician became involved with placing the orders the wait time was… [END OF PREVIEW] . . . READ MORE

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