Does practice match protocol? A comparison of "triage-to-provider" time among more- vs. less-acute ED patients.

Abstract

Abstract Introduction: The Emergency Severity Index (ESI) stratifies Emergency Department (ED) patients for triage, from 'most-acute' (level 1) to 'least-acute' (level 5). Many EDs have a split-flow model where less-acute (ESI 4 and 5) are seen in a Fast Track, while more-acute (ESI 1, 2, and 3) are seen in the acute care area. As a core principle of Emergency Medicine is to attend to more-acute patients first, deliberately designating an area for less-acute patients to be seen quickly might result in their being seen before more-acute patients. This study aims to determine the percentage of less-acute patients seen by a provider sooner after triage than more-acute patients who arrived within 10 minutes of one another. Additionally, this study compares the Fast Track and acute care areas to see if location affects triage-to-provider time. Methods A random convenience sample of 252 ED patients aged 18 or greater was taken. Patients were included if their ESI was available for the provider during sign-up. Patients were excluded if they were directly sent to the ED psychiatric area or attended by the author. We collected data on ESI level, timestamps for triage and first provider sign-up, and location to which patient was triaged (Fast Track vs. acute care). Paired patients ESI levels, locations, and triage and first provider sign-up times were compared. Results One hundred twenty-six pairs of patients were included. More-acute patients were seen significantly-faster after triage (~20 minutes) than less-acute patients in two groups: ESI level 2 vs. 3 and overall high- vs. low-acuity. However, in 34.8% of paired ESI 2 vs. 3 patients, the ESI 3 patient was seen prior to the paired ESI 2 patient, and in 39.4% of overall paired high vs. low acuity patients, the less-acute patient was seen before the more-acute patient. Additionally, patients in the acute care area had significantly-shorter median triage-to-provider times (~ 40 minutes) compared to those in the Fast Track area for ESI 2 (acute care) vs ESI 3 (Fast Track) and overall high-acuity (acute care) vs low-acuity (Fast-track). Nonetheless, approximately one-third of ESI 3 patients triaged to Fast Track were seen before ESI 2 patients triaged to the acute care area. Conclusion The split-flow model reduces overall ED length of stay (LOS), improving flow volume, revenue, and patient satisfaction. However, it comes at the expense of the fundamental ethos of Emergency Medicine and potentially subverts the intended triage process. Although most more-acute patients are seen by a provider sooner after triage than less-acute patients, a substantial number are seen later, which could delay urgent medical needs and impact patients' outcome negatively. Furthermore, acute care area patients are seen sooner post-triage than identical-ESI-level Fast Track patients, suggesting Fast Track might not function as intended. Further examination of patient outcomes is necessary to determine the impact of the ESI triage process and spilt-flow model. Categories: Emergency Medicine, Quality Improvement Keywords: Split-flow model, Triage, Emergency Severity Index (ESI), Emergency Medicine