This is a question many emergency departments struggle with due to the demands of increasing patient volume and increasing wait times. Many departments have successfully deployed physicians or advanced practice providers in an “up front” process that has patients seeing a provider first. However, this practice is fraught with problems if it is applied in the wrong setting and, as with many things, it is all about the details. Let me explain.
Emergency departments today are suffering due to multiple problems: ED volume is increasing, admission volume is also increasing and inpatient space is limited, the national nursing shortage is causing critically low staffing levels, and hospitals are careful where they are placing any available funds in hopes to achieve maximal returns. So, with some remarkable testimonies regarding physicians in triage, when is it time to do so? The answer lies in understanding what adding another physician achieves:
- Patients waiting can be seen more quickly (even in the waiting room).
- Orders are placed sooner in a patient’s stay, presumably decreasing length of stay (not a direct correlation).
- Patient wait times are reduced (time to provider only)
- Demand on ancillary services increases (more orders are being placed at any given time)
- Demand on nursing increases (orders placed must be carried out)
- Demand for space increases (physicians need a physical location to examine patients)
Given the increased demands an additional physician in triage brings, hospitals stumble in the following ways:
- Under staffing nurses: Adding a physician requires addition of nursing for support. There is no point in a physician placing orders that are not going to be carried out. This may “stop the clock” once the patient is seen, but it does not result in any benefit to the patient.
- Not taking into account patient acuity: If patients waiting are low acuity, a triage physician (or advanced practice provider) can make a significant impact. If they are high acuity, a triage physician is not significantly better than a seasoned nurse in determining triage level, and is incapable of making a large impact since many diagnostic services are likely to be needed. How many low acuity patients are required? At least as many as you would expect that physician or provider to see elsewhere. For example, an advanced practice provider should be able to see 3 patients an hour in triage if they are low complexity. Track hourly arrivals by acuity and make sure there is sufficient volume.
- Physical space: The triage physician will need space as will their support staff. If you expect them to work with only one or two small rooms, they will need dedicated space in the waiting room to use for a results waiting area.
Before you make the decision to place a physician in triage, ask these questions:
- Are you understaffed physicians ? Do patients frequently wait to see a physician or advanced practice provider? Or are they seen quickly once the provider has access to them?
- What is the acuity of patients waiting to be seen? If low, you may benefit from a provider in triage.
- What is the number of hourly arrivals with low acuity? If sustained, you could benefit from a provider in triage.
- Do you have two additional nurses you can dedicate to triage when a provider is out there? Remember that a physician or advanced practice provider is an expensive resource. Do not place them in an area knowing they will not be able to perform at maximum efficiency. If you are short nurses, consider paramedics as an alternative.
- Do you have space? At minimum, two rooms and a nearby section of the waiting room to utilize for results waiting.
If you answered yes to all these questions, then you are primed for a triage provider. If not, reconsider and we will address other possible solutions in the future posts.
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