Improving Emergency Department Flow by Using a Provider in Triage

Emergency Room Efficiency

Improving Emergency Department Flow by Using a Provider in Triage

Emergency room triage plays an essential role in the speed and quality of the emergency room departments. Triage represents only one small part of the process that determines quality of patient care. Emergency rooms can be crowded. Busy times are often unpredictable, making it difficult to avoid bottlenecks in the system. This has an affect on the amount of time between arrival and when the patient sees a physician. Patients can be in for frustrating long waits while sitting in the hospital lobby.Patients often leave the emergency room waiting areas without being seen because they get tired of waiting. These patients are referred to as left-without-being seen (LWBS). Reducing LWBS rates is crucial for improving quality of patient care in emergency rooms. Long waits also cause a potential liability for the hospitals, as patients that are critically ill may not be seen or assessed in time. Not only must the speed of triage be improved, but the accuracy as well. Accuracy is essential in the maintenance of quality patient care from the time of arrival until the patient leaves the facility.

This literature review will explore research on reducing emergency triage wait times and improving quality by including a Physician as part of the triage team. Vast research effort has been devoted to reducing emergency department wait times and improving quality. Numerous methods for reducing wait times have been explored as well. One of the most widely researched methods involved whether having a physician in the triage area reduced wait times and resulted in improved patient quality of care. The following explores these literature review results.

Although the topic of an emergency room wait times and quality has appeared in many mass media and professional publications, only credible academic research studies will be considered in conducting this literature review. Reducing emergency room wait times and quality of care, with a focus on the triage area has been a topic of research globally, as well as in the United States. Many relevant studies were found that were conducted outside of the United States. Only those that were relevant to the specific topic area and to hospital operations in the U.S. were considered. Several studies of international origin were included, as they significantly added to the ability to identify gaps and needs within the research parameters of this study.

The Issue of Emergency Room Crowding and Speed

Reducing emergency room wait times is an important topic for many reasons. McHugh and Van Dyke (2011) explored the need to reduce emergency department crowding and strategies to achieve this goal. The key findings were that reducing emergency department crowding reduces the quality of care. Secondly, it is costly and compromises community trust. The key to reducing emergency room crowding is to improve the patient flow throughout the emergency department and the rest of the hospital.

According to McHugh and Van Dyke, one of the key suggestions for improving patient flow is to develop a patient flow improvement team. Members of the team should include physicians, nurses, and support staff. It was further found that consideration of both team and hospital goals, as well as available resources were a key to the development of strategies for improving emergency department patient flow. Improving emergency department patient flow will involve many changes in procedures. It will require a culture change within the organization. Many staff members may be resistant, which represents one of the key obstacles that the team will face.

Elmqvist, Fridlund & Ekebergh (2012) found that performing lifesaving actions, while at the same time creating good relationships with the patient and next of kin, requires continuous movement between these two functions. Emergency room providers are under considerable stress due to time pressure and must develop different strategies to cope with their work. Redesign of internal work processes can help to reduce the stress experienced by emergency department personnel to help them find a balance between maintaining patient safety and next of kin relationships while performing their duties.

Aekun, Briggs, & Patel et al. (2010) evaluated factors both intrinsic and extrinsic that influenced patient throughput in emergency departments. The study used an observational design to determine the list of variables that played a role in patient wait times in the emergency department. Observations took place at 8:00 PM Monday through Friday during a three-month period. This method reduced the effect of busy and slow times at the hospital. Weekends are typically busier than weekdays and emergency departments. This method added consistency to the study method. Daily volume in the emergency room, patient acuity, staffing levels, occupancy, daily admissions, hospital volume, and intensive care unit volume were all taken into consideration in the analysis.

The study treated patients as samples for the purpose of the study. During the observation period the emergency department capacity averaged 85%. The door to physician time was 1.8 hours, with the biggest influence being the triage department. The day of the week and emergency department occupancy were found to play significant roles in the amount of time spent in the triage department. The triage department was cited in many studies as being the department most responsible for decreased patient flow times.

Types of triage and Effectiveness

Shea & Hoyt (2012) found that the traditional nurse triage model creates barriers in the process of rapidly evaluating patients when they first arrive at the emergency room. Strategies must be explored to improve time of arrival to the time they see a provider and undergo the screening process. The RAPID team triage system represents a change in the way triage is handled in the emergency room. The focus of this system switches from a hospital/system centered approach to a patient-centered approach.

Farroknia, Castron, & Elurenberg et al. (2011) performed a systematic review of studies on triage scales used by emergency departments. The ability of different scales to predict patient outcomes is a topic seldom addressed in academic research. However, this factor will play a key role in the ability to isolate the effects of the Physician in the emergency room from any effects that are caused by the various triage scales used by different emergency departments. The effect of various scales on triage in emergency department efficiency represents an external variable in this research study.

The ability to reproduce reliable results using the various scales is difficult to measure due to differences in patient circumstance and provider interpretation. The scales assessed in the study were the GRADE, CTAS, ATS, and METTS scales. It was found that information needed to assess the effectiveness of the scale in reducing death or hospitalization of patients assigned to the lowest two triage levels on five-level scales was inadequate to draw conclusions. The study utilized an examination of other studies regarding those various scales. The study showed that the risk of death was low for the lower triage categories, but the need for inpatient care was excluded from the study.

These study results were disturbing for many reasons. Evidence was insufficient to assess the validity of the scales, but their ability to distinguish the urgency of patients assigned five to different levels, regardless of the scale being used was poor. It was difficult to assess mortality rates among different triage levels, even with the adjustment of age and gender. This is largely because a higher risk of mortality is generally associated with higher triage scale levels, with the highest number on the scale representing the most urgent patients. The major concern of this study was the safety of the scales and their ability to accurately assign categories. Early death among the lower levels of triage patients was used as the study instrument. The ATS and CTAS scales only offered limited evidence in relation to their ability to assess the safety of patients. Patients assigned the lowest level of triage using the scale were found to have a low mortality rate within 24 hours after triage. However, it is not known if these results would change using a different patient population.

Even though evidence was limited, it appears that the scales are safe in respect to their assessment of lower levels of patient categories. Evidence regarding the METTS scale was inconclusive, as this is a newer scale that has recently been developed. At present, the METTS scale has only been employed in Swedish hospitals. It was noted that many external variables exist that could have affected the results of the study. These research studies included overall patient populations in the emergency department, access to hospital beds, the hospital admission policies, and the presence of inaccurate triage decisions. Measurement of the accuracy of the triage decision only considered patients that were assigned a lower category, rather than that which represented their actual urgency for treatment. The same variables will affect the current research study and will have to be addressed in the methodology portion of the study.

Farroknia, Castron, Elurenberg and associates were unable to draw definitive conclusions as to which scale was the most safe and effective of those examine. 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.

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.

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 reduced by 11 minutes. The study suggests that orders placed by a triage Physician do have a positive affect on emergency department operations by reducing the amount of time patients spend in an emergency department bed. This allows a higher throughput volume of patients.

The study by SoRelle does not support this finding. When one compares the two study methods, the study by Russ, Jones, & Aronsky represents a much larger sample population and a longer study period. It is not known if the results found by SoRolle would support these results had a longer time and larger sample population were used. The results of SoRelle shows little decrease in time spent in the emergency department, whereas the study by Russ, Jones, & Aronsky (2011) demonstrates a consistent decrease by 11 minutes.

It must be noted that the decrease in total time in the emergency department was decreased by 11 minutes in both studies. However, neither study noted that the time to treatment was impacted by a Physician in triage, only the total time spent in the emergency department. The reduction in total time spent in the emergency department found in both studies suggests that these results are consistent over a larger population and can be generalized to a larger patient population than was included in the studies.

A study conducted at Hemet Valley Medical Center explored reducing wait times and the number of people that walked out without being treated (LBWS) (Wesson, 2011). The program has been implemented during busy times and includes ambulance services that transport patients to the hospital. The new program reduced wait times for those that arrived by ambulance by nearly half. The new initiatives at this hospital were found to reduce stays in the emergency department from 7 1/2 hours to 2.7 hours. The study was conducted over one year period from October 2009 to October 2010. The study included 4,006 emergency room visits in 2009 and 3,828 visits in 2010. The number of patients that left without being seen was decreased from 15% to 1.9% the following year. No mention was made of the total time from intake to admission into the treatment area.

The Norwegian Board of Health has recommended that all hospitals must take action to improve waiting times before patients are seen by a Physician. This is the prevailing global attitude, with some areas having a greater need in this respect than others. A study by Hohn and Dahl (2009) examined introducing Physicians into the triage area every weekday from 10:00 AM to 7:00 PM. The study found that it was difficult to determine the effect that Physicians had on reducing waiting times because throughout the day, and on different days of the weight patient flow varried. At times they were inundated with the most severe cases and at others there were few, if any, high priority cases. Fewer high priority cased makes speedier times for those who are less severe. It was not felt that the results of the study were conclusive due to variations in patient load. Therefore, the researchers developed two simulation models to estimate the effect on patient wait times.

These simulations involved a scenario where a Physician replaced one of the nursing staff, rather than representing an increased staff in the area. The simulations found that wait times between time of arrival and initial Physician evaluation was reduced from 117 minutes to 26 minutes. However, after admission to the emergency department, the wait time for examination was only reduced by 7 minutes. The simulation demonstrated that total wait time in the emergency department was reduced from 297 to 288 minutes by introducing a Physician into triage. The results of this study are questionable because the initial research was inconclusive. The conclusions relied on a simulation model, but if the initial results were unable to compare parameters, the accuracy and reliability of the simulation models in their application to a real world setting must be questioned. Simulation models give the researcher better control of variables of the study, but if they do not reflect real world results they are of little use. In this study real world results could not be obtained, making the results of the simulation models in a real world application difficult to determine.

Martin-Sanchez, Gonzalez-Del, and Zamorano et al. (2007) conducted a study using a small sample group of 100 patients. Of these, only 45 were found to be eligible for the study. This study focused on the most acute patients according to initial triage. Of the 45 patients located, 10 were placed in the acute area, and 35 as urgent. Forty percent of those in the acute area were admitted and 20% of those placed in the urgent area were admitted. The triage Physician placed 12 of these patients in the acute area due to technical procedures and 8 were placed in this area due to the complexity of their case. The Physician criteria placed 33 in the urgent area. The complexity of the patients case as a reason for admission into the care area was 87.5% and 12.1% in the urgent area. This study is important as it addresses the quality of triage and its ability to accurately place the most severe cases in the acute area. The most important finding of this study is that many of the patients placed in the acute area not because of the severity of their condition, but because of the complexity of the case. This study indicated that the average triage staff has a low capacity for detecting acute patients with potentially high-complexity cases. The study concluded that assessment by a Physician in the triage area is necessary to guarantee proper placement in the appropriate triage category. It was felt that this practice represented optimal use of hospital resources and staff. This case indicates that a Physician in triage has a significant impact on the quality of care received by the patient.

A comparative study compared the quality and timeliness of triage when a Physician was present two times when a Physician was not present in the triage area (Holroyd, Bullard, & Latoszek et al. . 2007). The study took place over three two- week time periods. All seven days were randomized into study shifts in the other into control shifts. Outcomes assess patient length of stay, as well as a proportion of patients that left without assessment. It considered staff satisfaction and ambulance diversion rates. It was found that the department averaged 14 patients per shift and 15 telephone calls per shift. On average, they spent 781 minutes consulting on the phone. The average patient age, gender, and initial assessment at triage were found to be similar. Total length of stay in the triage area waiting room was found to decrease by 36 minutes when compared to control days. The rate of those that left without being seen decreased from 6.6% to 5.4% when a Physician was present. The number of ambulance diversions was similar on both test and control days. The study concluded that a Physician in the emergency room triage area has a significant positive impact during times of overcrowding. The study found that a Physician in the triage area improves patient outcomes and the quality of care provided.

Rowe, B., Guo, X. And Villa-Roel, C. (2011) performed in meta -analysis that included a systematic review of 28 studies from a potential 14,446 studies identitified. A majority of the studies were found to employ before and after designs. The results of the data analysis found that the presence of a Physician in the triage area resulted in shorter emergency department length of service, compared to triage that is staffed by nurses only. Contrary to single studies examined in this literature review, the study found no change in those that left without treatment. The analysis concluded that it appears that a Physician is helpful in reducing overcrowding during busy times and that they decrease the totals time spent in the department. However, the authors cautioned that further studies need to be conducted before this practice becomes widespread. Although cautionary statements can be found in several studies located during this literature review, the presence of a Physician in triage is becoming standard practice in many hospitals. The idea is becoming widespread, even though researchers do not feel enough information is available to determine the extent of this practice on positive patient outcomes.

Day, AL-Roubaie, and Goldlust (2012) found that the addition of a mid-level health care provider in an emergency department triage significantly decreased the processing time of patients. The study utilized a comparison between computer simulations and real-world interventions. The purpose of this study was similar to the present research in this study. It was to explore the effect on length of stay in emergency department triage. The study took place at a Veterans Affairs medical center emergency department. Using a physician and mid-level provider in triage effectively reduced stays in triage departments from 247 to 210 minutes. The study concluded that a physician in the triage department significantly reduces stays in that department and that the computer simulation used accurately predicted these results. This particular computer model demonstrated that it accurately predicted real world results, unlike the simulation utilized in Hohn and Dahl (2009).

Oredsson, Jousson, and Rogues et al. (2011) conducted a thorough literature review of studies related to reducing wait times and improving emergency department flow. The most important outcome of this study was that many studies were excluded as they did not include complete data on wait time, length of stay, and the number of patients that left the emergency room without being seen. All of this data is important for the study to be valid and relevant to the improvement of emergency department wait times and flow processing. The study found that introducing fast-track processing for patients that do not miss presentation of severe symptoms and results in shorter wait times overall. Team triage with a physician on the triage team also results in shorter wait times and a shorter length of stay in the emergency department. Having a physician in the triage department also reduced the number of patients that left without being seen. The findings of Jordan, Lietz, and Love et al. (2012) support these results. They found that the wait time decreased from 75 to 25 minutes when a Physician was relocated to the triage area. They also found that the percentage of patients leaving without being seen was reduced from 3.6% to 0.9%. This represents a measurable difference in the wait time to be seen and LWBS rates.

Burlingame (2009) found that hospitals are now concentrating on improving patient satisfaction, in addition health-related issues. One of the key factors in patient satisfaction is the wait time that they spend in the emergency department. The study found that mid-level provider in triage for the purpose of performing medical screening exams reduced emergency department wait times and increased efficient flow of patients through the system. They also found that these factors increased staff satisfaction. The study found that improving patient flow had a positive affect on improving patient satisfaction as well.

Soremekun, Capp & Biddinger (2012) found that using Physicians in the emergency room triage is one of the more recent developments in the quest to improve triage speed and patient flow in emergency departments. This study found that the inclusion of physicians in triage evaluation decreased the arrival to disposition decision by 6 minutes. Times for analgesia, antiemetic, antibiotic, and radiology orders decreased as much as 1 hour. The findings were statistically significant for all factors studied. Patient triage by Physicians was found to decrease the time for patients to be administered procedures, having a significant impact on health and satisfaction. Physicians in the triage were found to have a positive affect on patient outcomes and quality of treatment procedures. This study found that earlier triage led to earlier treatment.

Love, Murphy, and Lietz et al. (2012) found that having a physician in the triage area decrease patient wait times from 75 to 25 minutes. The number of patients that left without being seen decreased from 3.6% 20.9%. This practice also led to higher patient satisfaction. Fewer ambulances were diverted to other facilities due to wait times. Overcrowding in general was reduced in the emergency room. This study supports other studies found that indicate that physicians in the triage area significantly decrease wait times and patient processing times.

The study by Murrel, Offerman and Kauffman is an excellent addition this literature review because it serves as a point of comparison between various methods for reducing emergency department wait times. The study allows us to compare whether other methods of emergency department triage wait times have a similar effect to studies that concluded that physicians reduced wait times in triage.

The results of the study found that times between ambulance arrival and hospital admission were unchanged. Wait times reduced from 42 hours 23 hours. Implementation of the RTT system reduced the time that it took for patients see a physician from 62 minutes to 42 minutes. The number of patients who left without being seen decreased from 4.5% to 1.5%. This study allowed a comparison between methods to reduce wait time that involved physicians in a triage and ones that did not implement a physician, but rather relied on lean management techniques.

The results of both of these types of interventions demonstrated that each of them has a significant effect on emergency department triage. The results of studies that employed physicians in the triage varied in the amount of reduction of wait time and improved patient throughput. However, in some cases the studies were similar in results, thus leading to the conclusion that Lean Management techniques and having a physician in triage are both highly effective methods for reducing emergency room wait times. They were effective in decreasing the time from entrance to being seen by the physician, and in reducing the amount of patients that leave without being seen by a doctor. Both Lean Management style techniques and having a physician in the triage area proved to be effective methods for improving patient wait times.

An Issue of Quality

The Institute of Medicine mentions six dimensions of emergency department quality. These are safety, patient-centered approach, timeliness, efficiency, effectiveness, and equity (Bernstein, Aronsky, & Duseja, 2009). Emergency room crowding has a negative impact on all of these areas. Many studies focus on timeliness and efficiency as the key cornerstones of triage, but there are many more dimensions than just speed. These six quality factors must all be present in order for the patient to receive the best care possible. Insufficient studies exist to determine the extent to which emergency room crowding contributes to a loss in each of these quality areas.

Ekwali, Gerdiz, & Manias, (2008) studied satisfaction in emergency room care among individuals that accompany others to the emergency room. The triage area was found to be a key component in assessment of quality by the accompanying individual. Waiting time and time to treatment for the patient were primary components an assessment of the emergency department experience. Escorts are important for building future business and their perceptions of the patient experiences will have an impact on the future of the facility. The escorts' perception of the severity of the patient's condition was a key factor in their satisfaction with the emergency department. It was found that escort accompanying patients of higher urgency were more satisfied than those accompanying patients of low urgency. This may be due to the patients triage status and the ability to get care sooner. Younger persons also tend to be less satisfied than older persons in the emergency room.

Large scale disasters pose a particularly difficult problem for triage. They are the central hub of emergency operations. They must quickly identify the most critical patients and speed them through the process, while making certain not to miss critical patients that are deemed to be in a lower triage category. The capability to process and handle critical patients depends on the staff and number of treatment units that are available. The problem of overtriage and under triage has significant implications for patient outcomes. Under triage means assigning a lower triage value when the patient has more threatening conditions and should be a higher priority. Under triage can have an immediate negative impact on the patient as they will not receive the immediate care that they need. From this standpoint it would seem as if it would be better to err on the side of caution rather than denying a patient the care that they need.

The opposite of under triage is overtriage. This means assigning patients that are less severe to higher priority categories. It would appear that overtriage would be the lesser of the two conditions because it results in patients getting treated more quickly, even though their symptoms are less severe. However, several studies indicate that overtriage leads to a higher, overall mortality rate because those that need treatment, perhaps not immediately, but still within a reasonable time, frame do not get treated in time to keep their condition from worsening. Several studies found overtriage to be related to increased mortality rates in mass casualty situations (Armstrong, Hammond & Hirshberg, 2008; Hupert, Hollingsworth, & Xiong, 2007).

These studies highlight the importance of accuracy in triage. Assigning categories correctly can help to decrease patient mortality and also prevent further crowding of the emergency department. No studies could be located during the course of the literature review that examined specifically how Physicians could contribute to the quality and accuracy of triage. However, as the above examples of illustrate, the importance of accuracy in triage cannot be overemphasized. Hupert, Hollingsworth, and Xiong (2007) suggests that better metrics are needed to help nurses more accurately identify critical patients vs. those for whom delayed treatment will not affect their condition. Better metrics could help to improve the overall accuracy of triage and their importance cannot be denied. Future research needs to examine the question of whether a Physician in triage helps to decrease over and under triage during surges in the average emergency room and during a trauma situation. A Physician has much more education and experience than the average triage nurse. Their insight may prove valuable and reducing over and under triage.

Gentile, Vignally, and Durand, et al. (2010) found that the willingness of emergency to patients to accept a restructuring of the emergency department triage area demonstrates a lack of acceptance. Alternative structures were not found to be popular alternatives to reduce overcrowding.

Geuts, Palatnick, Strome and associates (2012) found that within the emergency department population a subset of patients exists who make frequent visits and that these patients significantly increase the overcrowding problem. Reducing frequent visitors, who present without cause must be reduced in order to improve the efficiency of the emergency department. When patients that do not really need to be there take up beds, quality of treatment may be compromised for those presenting more severe conditions. The study defined frequent emergency use as 15 or more visits over a one year period. Information was collected on those patients identified as "frequent fliers." Information as to their demographics, complaint upon entry, and discharge diagnosis, as well as their method of arrival were compared to the CTAS score and length of stay.

This sample population identified 92 patients that felt into this category. The population was dominated by middle aged males with no fixed address. 59% of the patients arrived by ambulance and presented with less acute scores than the average population. Substance use comprised nearly 26.9% of all complaints upon entrance. Females and those with abnormal vital signs were associated with increased the length of stay. Admissions were lower than in the general population and women were twice as likely as men to be admitted. This population was found to have high LWBS rates of nearly 15.8%. Interventions to decrease these frequent visits would play a major role in decreasing emergency department overcrowding. However, in doing so it must be cautioned that this must be accomplished without compromising quality of care or misidentifying those that truly present with acute conditions.

Beiler, Paroz and Faouzi et al. (2012) agreed with Gentis, Papatnick, Strome and associates in their assessment that frequent visitors the emergency room that present non-acute symptoms represent a major problem in the emergency department overcrowding issue. They used similar criteria as the previous study only they used a different population. Results were similar to the previous study and it was found that certain demographic groups had a greater probability of becoming frequent fliers than the general population. This information can help to isolate patients that may represent monurgent frequent fliers, but cautioned that demographics should not play a major role and diagnosis.

Matzer, Wisiak, Graninger and associates (2012) found that identification of a highly complex patient group resulted in clusters of patients that frequented the emergency room. Many of them were found to live alone. The study found that among the subgroup admission rates were also higher. Patients in the highly complex group received interventions addressing psychosocial factors more frequently than the general population or those identified in other patient clusters. Screening by social factors helped to identify potential frequent users of the emergency room, as well as identification of multidisciplinary Health Care needs.

Brooker, Ricketts and Bennett et al. (2007) found that admission rates were significantly increased in socially and financially deprived areas of the city. Suicide was a more common reason for referral as well as deterioration of an existing mental health problem. Crisis resolution and home treatments had no impact on these results. It was suggested that crisis resolution and home treatments target larger areas of greatest social need. In deprived areas patients presenting with suicide risk are likely to me more common. Standard health assessments in triage focus on physical health related issues. The study suggests that mental health crisis triage rating scales may be useful as an alternative to assess these patients.

Kalveci, Domiccan, & Keles et al. (2012) addressed the topic of agreement between paramedics and emergency residents regarding triage decisions using a three level triage system and a five level triage system. The study involved an Australian population and took place in real time. In this study patients were triaged by paramedics and by emergency residents. The results demonstrated that admitting time and waiting time were consistent in the waiting area. Agreement between paramedics and emergency read and since was 47% using the three-level scale and 45% using the five-level scale. Cases were not adjusted for gender, or medical history. Results were consistent across all of the cases examined. A strong correlation was found between the condition of the patients using both a three-level scale and the five-level scale. The study is significant for many reasons. First, it supports that triage performed by nurses and triage performed by paramedics is in agreement with that of emergency Physicians. This suggests that untrained personnel can conduct simple triage. However, the results of this study cannot override the overwhelming evidence that Physicians in the triage area improve the accuracy and quality of the decisions made. The study used a small sample, which may have affected the results.

Durand, Gentile, and Grebeaux et al. (2011) also addressed agreement in triage between the nurse and Physician. In this study, levels of agreement between the nurse and Physician were low. Three types of complaints were examined: cranial injuries, gynecological complaints, and toxicology complaints. The lowest level of agreement in these categories concerned two subgroups. Patients complaining of symptoms involving urinary-nephrology and previous hospitalization were found to represent the lowest amount of agreement between initial nurse and position assessment. It was found that emergency Physicians tended to categorize patients as a higher urgency than nurses. Physicians were much more sensitive in their categorization and more specific in their ability to assign appropriate categories to all patients in every category. This is an important study in relation to the current research dissertation as it demonstrates the importance and increased ability of the Physician in the triage area, A majority of the studies in this literature review found only insignificant or negligible increases in time from triage to treatment when a Physician was present. However, this study supports their value in the triage setting, aside from the time factor. This study suggests that Physicians represent a significant improvement in quality when utilized in the triage area. Accurate assessment of the patient and assignment to the appropriate treatment and tests is an important issue in quality of care in the emergency department.

This study is in conflict with a study by Kalveci, Domiccan, and Keles et al. (2012) that concluded that untrained personnel were just as effective in making triage decisions as higher level qualified staff. This study used a larger sample population and divided the sample into detailed categories, a step that was lacking in the previously mentioned study. For the purposes of this literature review, it appears that the study by Durand, Gentile, Grebeaus and associates is the more credible of the two. Therefore, Physicians in the triage area can be considered an important addition to the triage team, at least as far as quality is concerned.

Hoot and Aronsky (2008) examined the problem of emergency department crowding and its affect on the access to quality Health Care. Emergency department crowding was found to be a significant factor in the reduction of quality of care in emergency rooms. Those who frequent the emergency room unnecessarily, such as those with mild influencza during flu season, or who over assess their own condition were found to be key causes of emergency room crowding difficulties. Crowding was also related two inadequate staffing, too few hospital beds and inpatient boarding. The most serious effects of emergency room crowding were patient death, transport delays, treatment delays, ambulance diversion, and delays in treatment. Other affects included patients leaving without being treated, and a financial affect when the institution. This study highlights the importance of affective and accurate triage.

Solutions for overcrowding included the addition of personnel, the institution of observation units, increased access to hospital beds, and improvements in queuing theory. There are many facets to the overcrowding problem and solutions are expected to be complex. In an attempt to help resolve this issue, Schull, Kiss, and Szalai (2007) found that low-complexity patients are not associated with an increased emergency department stay and delays in first Physician contact for other emergency department patients. Reducing the number of low-complexity patients is not expected to have an affect on waiting times for other patients. It does not have an affect on crowding as it does not reduce total patient load.

Derlet and Richards (2008), found that limited bed capacity results in the boarding of admitted patients in the emergency department, rather than being admitted to their regular rooms. Overcrowding causes patients be placed in hallways, storage rooms, and annexes. One of the key problems is that some of the emergency department patients placed in the hallway are actually sicker than those already occupying hospital beds. It was found that the boarding of patients in the emergency department has a negative affect on congestion and is associated with poor patient outcomes as they do not rapidly receive the treatment that they need. The study makes the importance of triage even more important, but it also suggests that accurate triage assessment will not solve all of the issues because the order in which patients arrive cannot be controlled.

Derlet and Richards also found that the use of tests such as computed tomography (CT) used to be limited to patients with severe head and thoracic abdominal trauma. However, now close to 50% of all patients will receive CT scans. This includes those with minor head trauma, but, no pain, headache, or any soft tissue complaints. This is largely a result of improvements in the diagnostic ability of the CT scan. The speed of the scan has also increased, as well as the availability of machines. However, according to Derlet and Richards, the use of imaging tests have a negative impact on outcome. Indiscriminate ordering of CT scans significantly slows the speed of the emergency department flow. It is been suggested that many conditions for which CT scans are ordered could be diagnosed by other, faster means. The author suggests that the ordering of CT scans has become automatic rather than being used carefully. This habit ties up beds unnecessarily in the emergency department. Using more rapid tests on conditions warrant them may help to reduce emergency room crowding, thus having an impact on patient outcomes.

New alternatives in Triage

In the face of a pandemic triage becomes one of the most important areas of the hospital. They must move patients through quickly but also protect others from exposure to potentially harmful biological agents. In 2009, the H1N1 influenza sparked panic, resulting surge in emergency room visits. Many of the visitors to emergency rooms during this time do not actually have the pandemic, but anything that resembles similar symptoms will cause them to seek emergency attention. This creates several problems in the triage area. First, it creates overcrowding in the emergency room, delaying speedy treatment for those that are really sick. Second of all it exposes others that have not yet been exposed to the pandemic. The Strategy for Off-Site Rapid Triage (SORT) was developed to help both of these problems (Kellerman, Isakov & Parker, 2010). This triage method allowed those who believe they may be sick with the pandemic gain guidance through teleephone call centers to help determine those that were truly in need of a visit to the ER and those who have more common illness symptoms. This system uses Physicians in triage as a remote means of separating triage patients. The Center for Disease Control administered this program. Lines can be staffed in accordance with anticipated rises in caseload such as during a pandemic. In addition to phone support this system offered two interactive web sites to help adults self-assess whether they needed to visit the emergency room or not. SORT may prove be a valuable tool in helping to relieve emergency room crowding in the future. This is another capacity it allows Physicians to participate in a way that helps to minimize emergency room crowding.

Bedside registration has been found to streamline patient processing from the time they arrive to the time they leave. It has an impact will increasing patient satisfaction scores significantly (Cheung-Larivee, 2012). Acute patients are identified and processed through quickly. However, for less acute patients, which comprises a majority of the emergency room patients, bedside resident registration was found to be an effective means of allocating emergency room resources that are short. "Patient partners" are nonclinicians that greet emergency department patients and ask them their name, an identifier such as a birthday or social security number and to state their chief complaint. This process takes approximately 2 minutes (Cheung-Larivee, 2012). As this is going on a nurse or technician conducts a rapid assessment of the patient that includes traditional triage and ranking of their condition on a scale of 1 to 5. All of this happens at the same time, therefore saving time and streamlining the process. This process had a significant impact on reducing the number of patients that left the emergency department without being seen (Cheung-Larivee, 2012). The study also found that the chances a patient will leave without being seen increase with every extra hour of length of stay. This study also found that those that leave the emergency department without being seen have a greater likelihood of mortality within a seven day time. This improvement in emergency room efficiency is a result of reengineering the admission process so that it integrated with other emergency department functions. These new advances in triage represent potential solutions to the problems addressed in this and other studies.