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Three Part Question

[Does putting a doctor in the triage area] [improve waiting time] of [patients in the Emergency Department]?

Clinical Scenario

You are the Head of Emergency Department (ED) and are currently facing the problem of overcrowding at the ED.
Many Emergency Departments (EDs) also face the problem of overcrowding.1-3 According to the Joint Commission on Accreditation of Healthcare Organisations (JACHO) in the United States, ED overcrowding was a contributing factor for 31% of cases of mortality or permanent injury from delayed treatment.2
Many measures have been taken to reduce waiting time in the ED, including increased staffing of doctors and nurses, increased trolleys and beds for short stay.4 Some studies have even explored the effect of "fast-track"5-6 or rapid assessment clinics7 on reduction of ED overcrowding.
Triage has traditionally been performed by nurses.8 Putting a doctor at the triage area may potentially relieve congestion in the EDs as the doctor can promptly assess the patients and initiate treatment, especially for those with minor injuries and illnesses. The objective of this study is to review the evidence for putting a doctor at the triage area of an Emergency Department.

Search Strategy

Medline (1950-2007), Embase (1980-2007), CINAHL (1982-2006), The Cochrane Library, Web of Science and CAB Direct, citation search from the reference list of the retrieved articles, hand searching of Emergency Medicine Journal and Emergency Medicine (also called Emergency Medicine Australasia).
[exp Emergency Service, Hospital/ (MeSH) or emergenc$ (free text)] AND [exp Triage/ (MeSH) or triag$ (free text)] AND [exp time and motion studies / or exp time factors (MeSH) or time($) (free text)]

Search Outcome

4 articles met the inclusion criteria from the full-text. The search ended on 6 August 2007. Quality appraisal for the design, analysis and interpretation of these papers was made using a checklist developed by SH Downs and N Black.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

Study 210 was a randomised controlled trial (RCT)10 while Study 11, 32 and 48 were non-randomised comparative studies with historical control respectively between 2004 and 2006. The inclusion criteria did not appear consistent in all studies. In Study 1 and 2, all new patients were included.1,10 In study 3 and 4, only patients with less serious conditions were included.2,8 All the studies revealed that waiting time to see a doctor was shorter in the intervention period than in the control period. Study 1, 2 and 4 showed that there was a statistically significant decrease in waiting time (p-values <0.001 to 0.029). 1,8,10 Study 3 showed no statistically significant decrease in waiting time (p-value 0.383)2 but this could be attributed to the small sample size. Study 1 and 2 showed that placing a doctor at triage reduced waiting time for radiography (p <0.001 to 0.029). 1,10 All the studies in this review showed that waiting time was reduced by putting a doctor at triage area. 1-2,8,10 There were, however, some methodological issues. Only Study 2 was a RCT.10 According to the hierarchy of study designs for effectiveness studies, RCT is considered the gold standard as it carries less risk of bias and confounding and provides causal inferences.11 The validity of other non-randomised studies could be affected by possible selection bias. Although it was not known if the confounding factors could be distributed randomly between the intervention and control periods, it was worth noting that Study 1 described the comparability between the intervention and control periods based on types of cases (e.g. x-ray, admission, urgency).1Another limitation was the publication bias: studies with positive findings are more likely to be published.12 There are limited data on a number of outcomes in the studies. While the outcomes in this review are waiting time to see a doctor and for radiography, there are other measures not consistently used in these studies. Examples are the length of stay at ED, number of patients who left ED without being seen or completion of treatment and proportion of patients seen within 30mins. Further review on these outcomes is needed. These studies were conducted only in developed countries. It was unknown if the results could be generalised to developing countries where there are concerns about lack of doctors for triage and inadequate resources (e.g. cost of equipment and manpower). Furthermore, it was difficult to compare results due to different seniority of doctors and number of triage staff in these studies and generalise to the real settings. Despite the heterogeneity in methodological quality and designs, the direction of effect from the main findings was consistent. It was commendable that these studies had provided the evidence and raised the need for us to look into new practices such as putting a doctor at triage area to address overcrowding at the EDs. The studies only demonstrated the effectiveness of placing a doctor at triage in reducing the waiting time at the EDs. Besides effectiveness, one needs to consider the resources (e.g. cost of equipment and manpower) which could be potential barriers to placing a doctor at triage area. It is also important that the quality of care and safety of patients in triage are not compromised due to heavy workload of the triage doctor with resultant medical errors made.

Clinical Bottom Line

Having found and appraised all the evidence and presented data in the evidence table, there was an overall effectiveness of placing a doctor at triage to reduce waiting time at the EDs. In view of the paucity of studies, further research, especially large-sized well conducted RCTs, is needed.

References

1. Choi YF, Wong TW, Lau CC, Wardrope J. Triage rapid initial assessment by doctor (TRIAD) improves waiting time and processing time of the emergency department. Emerg Med J 2006; 23:262-5.