Author, date and country | Patient group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
---|---|---|---|---|---|
Cheng I et al 2013 Canada | Non-critically ill ED patients, 8:00-14:30 during 131 weekday shifts across 26 weeks (65 days randomised to intervention and 66 days to control cluster).(n=6,300 pts, 750 seen by doctor). Academic tertiary level hospital. | Cluster randomised controlled trial | - Median ED LOS for patients discharged home from ED | - ED LOS decreased by 28min for high acuity patients (4:01hrs v 4:29hrs) (p=0.01) and 58min for low acuity patients (1:10hrs v 2:08hrs) (p<0.001) receiving intervention. | - There was an extra nurse at triage as well as extra EP, which may account for some benefits seen. - Evenings and weekends not studied. - Single-centre trial. |
- Median ED LOS for patients admitted from ED | - ED LOS for patients referred to other specialties/ admitted did not decrease significantly. | ||||
- LWBS (left without being seen) rate | - LWBS rate decreased by 0.7% (1.5% v 2.2%). | ||||
- Time to investigations (imaging, laboratory) | - Time to investigations all reduced. | ||||
Holroyd BR et al 2007 Canada | All adult ED patients, 11:00-20:00 during 42 days (21 control and 21 intervention shift days). (n=5,718 pts). Academic urban tertiary ED. | Randomised controlled trial | - ED LOS | - ED LOS decreased by 36min (4:21hrs v 4:57hrs). | - No power calculation. - Additional member of staff employed for intervention, therefore extra staffing may account for some benefits (rather than specific physician in triage role.) - Single-centre trial. |
- Proportion of patients who LWBS | - LWBS decreased from 6.6% to 5.4% (statistically non-significant). | ||||
Russ S et al 2009 USA | All adult ED patients. Physician at triage 11:00-23:00, 5-6 days per week. (n= 10,901 matched pairs of pts). Urban academic tertiary care Medical centre. | Retrospective data collection, comparing patients receiving physician orders at triage with matched control patients not receiving physician orders | - ED LOS | - Median ED LOS increased by 11min for those receiving triage orders. | - Comparison is between patients who do and don’t receive physician orders at triage, rather than all patients who are assessed by a physician at triage. - No randomisation of patients in intervention/control groups - potential bias. - Single centre study. |
- Waiting room time | - Median waiting room time increased by 41min for patients receiving intervention. | ||||
- Time spent in ED bed | - Median time in ED bed decreased by 37min for patients receiving intervention. | ||||
Soremekun OA et al 2012 USA | All medium acuity adult ED patients who were subsequently admitted, 11:00-23:00 over 2 year period (12 month pre- and 12 month post-intervention). (n=20,312 pts). Large urban teaching hospital. | Retrospective study - 12 months pre- and post-introduction of physician at triage | - ED LOS | - ED LOS decreased by 13 min (p=0.001). | - Retrospective design. - No randomisation. - Increase in admissions by 14% between the two study periods - Used physician order time on computer which was probably later than time seen, possibly underestimating the effect. - Single centre study. |
- Time to disposition decision | - Median time to disposition decision decreased by 6min (260min v 254min) (p=0.025). | ||||
- Time to physician evaluation and time to physician orders for analgesia, antiemetic, antibiotics, and radiology | - Median times to physician orders all decreased by 16 - 70 min | ||||
Jarvis et al 2014 UK | All ED patients (adult and paediatric) between 09:00-17:00, excluding minor injuries, during control phase (54 days) and intervention phase (19 days). (n=4,622 pts). District general hospital ED (major trauma unit). | Prospective, non-randomized observational study | - Time to ‘emergency department ready’ (ED management complete) | - Median time to ‘emergency department ready’ reduced significantly by 53mins (129mins v 76mins) (P<0.0001) | - Point of care testing was implemented alongside rapid physician assessment at triage, therefore cannot analyse impact of doctor at triage alone. - Triage consultant was additional member of staff. - Control and intervention phases were during different seasons – other factors may have affected outcome measures. - Single-centre study. |
- Time to first clinical assessment (Dr or nurse) | - Median time to first clinical assessment reduced by 8mins (12mins v 4 mins) (P<0.0001) | ||||
Imperato J et al 2012 USA | All ED patients (adult and paediatric), 13:00-21:00 during 6 months (3 month control and 3 month intervention period). (n=17,631 pts). Small community teaching hospital. | Retrospective study – 3 months pre- and post-introduction of physician at triage | - ED LOS | - Overall median ED LOS reduced by 13 min (3:48hrs to 3:35hrs) (p <0.001). This reduction was greater for admitted patients than for discharged ones (24min vs 7min). | - Retrospective study. - PIT (Physician in Triage) only for 8hr per day (13:00-21:00), whilst data from 24hrs included in results. - Average daily volume was higher during the intervention period and also less experienced staff were used during the intervention, both of which may reduce the effect. - Additional doctor used during intervention – results possibly due to increased staffing. - Single centre study. |
LWBS rate | LWBS rate decreased from 132 to 121 pts (non-significant). | ||||
Han JH et al 2010 USA | All ED patients, during 18 week period (9 weeks pre- and 9 weeks post-intervention). Physician triage 13:00-21:00. (n=17,265 pts). Urban academic tertiary care and Level I trauma centre. | Retrospective study - 9 weeks pre- and post- introduction of physician at triage | - ED LOS for admitted and discharged patients | - Median ED LOS overall decreased by 11min for whole cohort, but no significant difference in ED LOS for admitted patients, due to exit block. | - Retrospective data collection. - Triage physician was additional member of staff therefore extra staffing may account for some benefits seen. - Data collected for patients in 24hr periods whilst intervention for only 8hrs per day –Short study period. - Single-centre study. |
- LWBS rate | - LWBS decreased from 4.5% to 2.5%. | ||||
Rogg JG et al 2013 USA | All medium-acuity ED patients (adult and paediatric), during 1 year pre- and 3 years post- introduction of START (Supplemented Triage and Rapid Treatment). (n= 180,871 pts (39,142 pre- and 141,729 post-intervention)). Large, urban, academic tertiary care ED and Level 1 trauma centre. | Large retrospective, observational, before-and-after study | - ED LOS - for patients eligible for START intervention | - Median ED LOS decreased by 56min for pts eligible for START. | - Retrospective study. - Changes in ED data across study period – eg. annual ED volume increased by 12% from pre- to post-intervention and increase in nurses. - Single-centre study. - No blinding or randomisation. |
- ED LOS for all ED patients | - ED LOS for all pts (including low/high acuity) decreased by 30mins. | ||||
- LWBS rate | - LWBS rate decreased from 4.8% to 2.9%. | ||||
Gray et al 2009 Canada | All ED patients, during 4hr afternoon shifts across 6 weeks (3 control and 3 intervention weeks). (n=5,020 pts). Large urban ED. | Clinical controlled trial | - ED LOS | - ED LOS did not reduce significantly (396min v 409min) (p=0.32). | - Only had physician in triage for 4hr shifts. - Single centre study. |
- LWBS rate | - LWBS rate decreased from 6.3% to 5.7%. | ||||
- Time to see physician | - Mean time to see physician did not reduce (111min v 112min) (p=0.61). | ||||
Asha et al 2013 Australia | Ambulant ED pts age >16yrs who were selected by triage nurse as appropriate for consultant assessment, arriving 12:00-18:00 Fri-Mon across 3 months (intervention group). Control group – all ED pts 12:00-18:00 Tues-Thurs in same 3 months. (n=18,962 pts). ED of tertiary referral centre. | Prospective, non-randomised cohort study | - Proportion of pts meeting 4hr target in different subcategories (per whole day, between 12:00-18:00, in admitted pts, in discharged pts) | - Odds of pts meeting 4hr target, when controlled for confounding effects, was 15% higher on intervention days (P < 0.001). | - Pts were initially triaged by a nurse, and then those selected were sent to a SAS (Senior Assessment and Streaming) team including consultant, nurse and intern. Therefore results not strictly/only based on physician at triage. - No randomisation, and intervention was carried out on peak days only - Physician at triage was additional staff member - Single-centre study |
- LWBS rate | - LWBS rate improved by 0.34% (2.5% v 2.84%) (p=0.17); when controlled for confounding LWBS was 28% lower (P=0.003) | ||||
Partovi SN et al 2001 USA | All ED patients (adult and paediatric), 09:00-21:00 on 16 consecutive Mondays (8 intervention and 8 control shifts). (n=1,734 pts). Academic, urban hospital. | Prospective controlled trial – non- randomised | - ED LOS | - Mean ED LOS decreased by 82min (363min v 445min). | - Single-centre trial. - No randomisation or blinding used. - US health system very different to NHS. |
- LWBS rate | - LWBS rate decreased by 46% (7.9% v 4.7% patients). |