Senior doctor triage in the emergency department

A collaboration between the University Of Sheffield and the Yorkshire and Humber Academic Health Science Network (AHSN) Improvement Academy.

Background

With the increasing problem of poor flow and crowding in emergency departments (EDs), there is a growing interest in whether senior doctor triage (SDT) can improve flow and departmental performance.

This improvement project aimed to develop and test a senior doctor-led triage process for patients arriving by ambulance to the ED that would reduce the time from arrival to triage for patients and consequently reduce the time to treatment and overall time spent in the ED.

Aim

Develop and share best practice recommendations for the process of Senior Doctor Triage within emergency departments through evaluation of existing services in the Yorkshire and Humber region and bringing together a collaboration of up to three emergency departments.

Objectives

Undertake a regional survey of all EDs in the Yorkshire and Humber region in relation to how patients are triaged on arrival at the department. The survey will identify many different strategies, especially in relation to the use of senior doctors to triage patients on arrival, and potential emergency departments to work in the collaboration for further evaluation. Feedback on the regional survey results in a short report to all hospital sites in the region.

Build a collaboration of up to three EDs with a view to gathering more detailed information on the Senior Doctor Triage employed in their emergency departments and how it links with pre- and post-hospital emergency care services. A comprehensive assessment using a mixed methods approach (quantitative and qualitative) will be employed enabling the clinical effectiveness and cost-effectiveness to be evaluated as well as how the different triage strategies work for those involved i.e. staff and patients.

The collaboration will generate a set of recommendations for best practices to be shared and disseminated throughout the region. An ED within the collaborative will incorporate one or more of the recommendations, using hospital metrics to measure improvements. Undertake a number of information-sharing events where the results of the survey and good practice recommendations can be shared and discussed.

Re-organising staff and utilising a small additional resource (computer, scanner and mobile phone) in a single ED to deliver senior doctor triage significantly reduced the time to decision-making and the overall time patients arriving by ambulance spent in the ED.

Funding

This improvement project was funded by the Yorkshire and Humber AHSN Improvement Academy as part of the Communities of Improvement programme (£193,000). It started in August 2014 and closed in July 2016.

Publications

Abdulwahid MA, Booth A, Kuczawski M & Mason SM (2016) The impact of senior doctor assessment at triage on emergency department performance measures: systematic review and meta-analysis of comparative studies. Emergency Medicine Journal, 33(7), 504-513.

Results

The project operated in two phases. During the first phase, the project team visited each ED in the Yorkshire and Humber region to complete a survey and observe how the ED and staff worked, whilst also forming relationships with senior ED clinicians.

This was collated into a report detailing existing ED resources, facilities and processes in each ED and presented at a regional workshop generating new and sharing existing ideas for improving the speed and appropriateness of care for patients arriving in the ED.

The second phase of the project involved working with staff in an acute NHS hospital based in England to support staff in identifying and implementing improvements to their existing triage process. An SDT process was developed using existing resources over 6 months (September to March 2016), and tested during an implementation week (25th to 29th April 2016).

Patients arriving by ambulance to the ED between 10:00 and 16:00, Monday to Friday during the implementation week were included. Anonymised routine hospital ED data was collected and compared with 6 control weeks where standard nurse triage was operated (4 pre- and 2 post-implementation weeks).

Median times in the ED were significantly reduced for ambulance patients during the implementation week, time to triage (3 min v 10 min, p<0.001), the decision to admit (80 min v 133 min, p<0.001), and total time in ED (127 min v 224 min, p<0.001). More ambulance patients were admitted or discharged within 4 hours during implementation week (94% [97/103] v 64% [147/228]).

Patients arriving by other modes also experienced a reduction in the median total time spent in the ED (134 min v 137 min, p=0.066).