The Effect of Triage Diagnostic Standing Orders on Emergency Department Treatment Time

doi:10.1016/j.annemergmed.2010.05.016

Annals of Emergency Medicine

Volume 57, Issue 2, February 2011, Pages 89-99.e2

https://doi.org/10.1016/j.annemergmed.2010.05.016 Get rights and content

Study objective

Triage standing orders are used in emergency departments (EDs) to initiate evaluation when there is no bed available. This study evaluates the effect of diagnostic triage standing orders on ED treatment time of adult patients who presented with a chief complaint for which triage standing orders had been developed.

Methods

We conducted a retrospective nested cohort study of patients treated in one academic ED between January 2007 and August 2009. In this ED, triage nurses can initiate full or partial triage standing orders for patients with chest pain, shortness of breath, abdominal pain, or genitourinary complaints. We matched patients who received triage standing orders to those who received room orders with respect to clinical and temporal factors, using a propensity score. We compared the median treatment time of patients with triage standing orders (partial or full) to those with room orders, using multivariate linear regression.

Results

Of the 15,188 eligible patients, 25% received full triage standing orders, 56% partial triage standing orders, and 19% room orders. The unadjusted median ED treatment time for patients who did not receive triage standing orders was 282 minutes versus 230 minutes for those who received a partial triage standing order or full triage standing orders (18% decrease). Controlling for other factors, triage standing orders were associated with a 16% reduction (95% confidence interval −18% to −13%) in the median treatment time, regardless of chief complaint.

Conclusion

Diagnostic testing at triage was associated with a substantial reduction in ED treatment time for 4 common chief complaints. This intervention warrants further evaluation in other EDs and with different clinical conditions and tests.

Introduction

Previous studies have addressed the importance of length of stay as a measure of quality and efficiency of care in the emergency department (ED).1, 2 According to nationally representative ED visit data, ED length of stay in the United States, defined as the time from patient registration to physical departure from the ED, has steadily increased from a median of 132 minutes in 2001 to a median of 154 minutes in 2005.³ Longer ED length of stay is associated with a host of negative sequelae, including adverse clinical outcomes, ambulance diversion, patient dissatisfaction with ED care, and greater stress on clinical staff.1, 4, 5, 6

A number of factors are associated with longer ED length of stay. Clearly, crowding and the factors that cause crowding, such as boarding and high hospital occupancy rates, increase the time patients spend in the ED.7, 8, 9 Higher resource utilization, specifically receipt of advanced imaging tests and a greater number of screening tests, is associated with a longer ED length of stay.3, 10, 11, 12 Slow turnaround times from ancillary services such as specialty consultations and laboratory and radiology services also lengthen the ED visit.12, 13, 14, 15 EDs across the country have adopted a number of structural and process changes such as expansion of ED capacity (including the creation of fast-track and observation unit venues), active inpatient bed management, adding a physician to triage, and bedside registration to improve operational efficiency and decrease ED length of stay.16, 17, 18, 19, 20, 21, 22

Triage standing orders are another process strategy that may decrease ED length of stay.²³ Standing orders are medical orders developed for particular types of patient conditions or complaints that nursing staff use to carry out specific studies and procedures in advance of physician evaluation.²³ Derived from consensus and common clinical practice guidelines, standing orders enable more immediate intervention, potentially improving patient care and outcomes.23, 24, 25, 26 In the ED, triage standing orders allow triage staff to initiate diagnostic, therapeutic, and management regimens before provider examination for patients who cannot be immediately placed in a treatment bed.

The purpose of this study was to evaluate the effect that triage standing orders have on the treatment time of ED patients. For specific conditions, triage nurses at our facility can initiate either a partial or full triage standing order set for patients who cannot be immediately placed in a treatment room. We hypothesized that the receipt of triage standing orders (partial or full set) would shorten the treatment time for patients who received them. We also hypothesized that patients who received a full triage standing order set would be treated more quickly than those who received a partial triage standing order set.

Section snippets

Study Design

We conducted a retrospective, nested cohort study of patients treated in one community teaching-affiliated ED during a 32-month period beginning in January 2007 and ending in August 2009. All adult patients who presented with conditions for which triage standing orders had been developed and who waited at least 15 minutes to be placed in a room after triage were eligible. We categorized all study subjects into one of 3 study groups: (1) did not receive any diagnostic testing at triage; (2)

Results

Of the 38,719 adult patients presenting with one of the 4 study conditions, 15,188 (39%) met eligibility criteria. Approximately 25% of the study patients received a full triage standing order set, 56% received a partial triage standing order set, and 19% received diagnostic orders in the room (Figure 1). Table 1 summarizes the percentage of patients who received diagnostic tests at triage according to chief complaint category. Regardless of chief complaint, most patients received partial or

Limitations

The results of this study should be interpreted within the context of the following limitations. First, patients were not randomized to their treatment assignment. The use of triage standing orders, full or partial, was at the discretion of the triage nurses. We used a propensity score to balance the study groups on characteristics we measured that were systematically different between the groups. However, we were not able to balance the groups on unmeasured cofounders. For example, there may

Discussion

Because crowding shows no signs of abatement, EDs must develop strategies that optimize ED throughput without compromising the quality of emergency care. With this goal in mind, we evaluated the effect of triage standing orders on ED treatment time. Triage nurses used triage standing orders more frequently during crowded periods at the study ED. After controlling for differences between the study groups, we found that partial or full triage standing orders were associated with a 16% reduction

References (33)

L.I. Horwitz et al.
US emergency department performance on wait time and length of visit
Ann Emerg Med
(2010)
J.C. Moskop et al.
Emergency department crowding, part 1—concept, causes, and moral consequences
Ann Emerg Med
(2009)
R.L. Gardner et al.
Factors associated with longer ED lengths of stay
Am J Emerg Med
(2007)
T.C. Chan et al.
Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, lengths of stay, and rate of left without being seen
Ann Emerg Med
(2005)
B.R. Asplin
Measuring crowding: time for a paradigm shift
Acad Emerg Med
(2006)
A. Herring et al.
Increasing length of stay among adult visits to US emergency departments, 2001-2005
Acad Emerg Med
(2009)
S.L. Bernstein et al.
The effect of emergency department crowding on clinically oriented outcomes
Acad Emerg Med
(2008)
N.R. Hoot et al.
Systematic review of emergency department crowding: causes, effects, and solutions
Ann Emerg Med
(2008)
M.L. McCarthy et al.
Crowding delays treatment and lengthens emergency department length of stay, even among high-acuity patients
Ann Emerg Med
(2009)
P.V. Asaro et al.
The impact of input and output factors on emergency department throughput
Acad Emerg Med
(2007)

R.K. Khare et al.

Adding more beds to the emergency department or reducing admitted patient boarding times: which has a more significant influence on emergency department congestion?

Ann Emerg Med

(2009)

J. Pines

Trends in the rates of radiography use and important diagnoses in emergency department patients with abdominal pain

Med Care

(2009)

P. Yoon et al.

Analysis of factors influencing length of stay in the emergency department

CJEM

(2003)

L.S. Zun

Analysis of the literature on emergency department throughput

West J Emerg Med

(2009)

M.D. Menchine et al.

On-call specialists and higher level of care transfers in California emergency departments

Acad Emerg Med

(2008)

R.S. Lee et al.

Consultations in the emergency department: a systematic review of the literature

Emerg Med J

(2008)

Cited by (50)

Assessment of the patients’ outcomes after implementation of South African triage scale in emergency department, Egypt
2022, Chinese Journal of Traumatology - English Edition
Overcrowding in emergency department (ED) is a concerning global problem and has been identified as a national crisis in some countries. Several emergency sorting systems designed successfully in the world. Launched in 2004, a group of branches in South African triage scale (SATS) developed. The effectiveness of the case sorting system of SATS was evaluated to reduce the patient's length of stay (LOS) and mortality rate within the ED at Suez Canal University Hospital.
The study was designed as an intervention study that included a systematic random sample of patients who presented to the ED in Suez Canal University Hospital. This study was implemented in three phases: pre-intervention phase, 115 patients were assessed by the traditional protocols; intervention phase, a structured training program was provided to the ED staff, including a workshop and lectures; and post-intervention phase, 230 patients were assessed by SATS. All the patients were retriaged 2 h later, calculating the LOS per patient and the mortality. Data was collected and entered using Microsoft Excel software. Collected data from the triage sheet were analyzed using the SPSS software program version 22.0.
The LOS in the ED was about 183.78 min before the intervention; while after the training program and the application of SATS, it was reduced to 51.39 min. About 15.7% of the patients died before the intervention; however, after the intervention the ratio decreased to 10.7% deaths.
SATS is better at assessing patients without missing important data. Additionally, it resulted in a decrease in the LOS and reduction in the mortality rate compared to the traditional protocol.
Assessing the impact of tourist flows on emergency department treatment speed for residents and tourists. The case of Sorrento
2021, Socio-Economic Planning Sciences
Tourism is a fundamental lever of the economic and cultural development of a location. Large tourist flows can negatively impact the provision of public services, such as healthcare. This study aims to investigate emergency department (ED) treatment speed under increased demand caused by tourism. The analysis was conducted on data (covering March–October 2018) collected from the ED of a hospital in Sorrento, a renowned coastal tourist destination in Campania, Italy, by using a two-step strategy. First, we resort to the Kaplan-Meier method to compare treatment in the ED between residents and tourists. Second, through the Cox proportional hazards model, we study the impact of group-specific characteristics on the speed of treatment. The main empirical findings highlight that treatment speed is highly influenced by age and by the languages spoken by tourists. Foreign tourists are best served in off-peak periods, while in the peak arrival period, the healthcare system experiences difficulties, especially for those facing higher language barriers. What emerges is the necessity for a tourism destination to adopt measures to cope with the language heterogeneity of tourists. In a multi-cultural touristic context, healthcare providers and institutions should address the challenge of language barriers by using specialist interpreter services.
Triage Nurse-Ordered Testing in the Emergency Department Setting: A Review of the Literature for the Clinician
2021, Journal of Emergency Medicine
Citation Excerpt :
Of these, 13 articles were selected for inclusion because they addressed one or both of the study questions. Each of the selected articles was subjected to detailed review by the authors and assigned a grade of evidence based on focus, research design, and methodology (Table 3) (6–18). Ten studies assessed ED LOS, and among these, one study assessed time to diagnosis (6–16).
In an effort to decrease length of stay (LOS) and reduce overcrowding, many emergency departments (ED) have implemented triage nurse-ordered testing.
To review the medical literature to determine the utility of triage nurse-ordered testing and to offer evidence-based recommendations to emergency physicians.
A systematic search of the PubMed literature was performed for publication in English from inception to November 30, 2019 using a combination of the following keywords: “triage,” “nurse,” “protocol,” and “emergency.” The articles were screened for relevance and the selected studies were subjected to detailed review by all of the authors and assigned a grade of evidence based on focus, research design, and methodology. Recommendations were drawn from the findings.
The initial search yielded a total of 982 potentially relevant studies; 13 articles were ultimately selected for inclusion. Of these, 10 studies assessed ED LOS, with one study assessing time to diagnosis. The three remaining studies compared triage nurse-ordered testing with physician testing in the ED setting.
Triage nurses have reasonably similar accuracy as physicians in ordering limb x-ray studies and moderate accuracy for laboratory testing. However, we did not identify a clinically meaningful decrease in ED LOS from the use of nursing triage orders.
Triage Standing Orders Decrease Time to Antibiotics in Neonates in Pediatric Emergency Department
2020, Journal of Emergency Nursing
Infants aged 0 days to 28 days are at high risk for serious bacterial infection and require an extensive evaluation, including blood, urine, and cerebrospinal fluid cultures, and admission for empiric antibiotics. Although there are no guidelines that recommend a specific time to antibiotics for these infants, quicker administration is presumed to improve care and outcomes. At baseline, 19% of these infants in our emergency department received antibiotics within 120 minutes of arrival, with an average time to antibiotics of 192 minutes. A quality improvement team convened to increase our percentage of infants who receive antibiotics within 120 minutes of arrival.
The team evaluated all infants aged 0 days to 28 days who received a diagnostic evaluation for a serious bacterial infection and empiric antibiotics in our emergency department. A nurse-driven team implemented multiple Plan-Do-Study-Act cycles to improve use of triage standing orders and improve time to antibiotics. Data were analyzed using statistical process control charts.
Through use of triage standing orders and multiple educational interventions, the team surpassed initial goals, and 84% of the infants undergoing a serious bacterial infection evaluation received antibiotics within 120 minutes of ED arrival. The average time to antibiotics improved to 74 minutes.
The use of triage standing orders improves time to antibiotics for infants undergoing a serious bacterial infection evaluation. Increased use, associated with nurse empowerment to drive the flow of these patients, leads to a joint-responsibility model within the emergency department. The cultural shift to allow nurse-initiated work-ups leads to sustained improvement in time to antibiotics.
The cost of time: A randomised, controlled trial to assess the economic impact of upfront, point-of-care blood tests in the Emergency Centre
2019, African Journal of Emergency Medicine
Citation Excerpt :
These standing orders, however, have not utilised POC devices or have only been instituted when the EC is full. There has also been inconsistent uptake by staff with resultant inappropriate testing [13,14]. Significant time-saving has recently been shown with upfront, POC testing performed prior to the patient being assessed by the doctor in the EC [15].
Time and cost constraints abound in the Emergency Centre (EC). These resource-constraints are further magnified in low- and middle-income countries (LMIC). Almost half of all patients presenting to the EC require laboratory tests. Unfortunately, access to laboratory services in LMIC is commonly inadequate. Point-of-Care (POC) tests may assist to avert this shortcoming. The aims of this study were to evaluate the cost effectiveness of upfront POC blood tests performed prior to doctor assessment compared to the standard EC workflow.
A secondary analysis was performed on data from a prospective, randomised, controlled trial where patients with abdominal/chest symptoms or generalised body pain/weakness followed either the normal EC workflow pathway or one of two enhanced workflow pathways with POC tests (i-STAT with and without a complete blood count (CBC)) prior to doctor evaluation. The incremental cost effectiveness ratio (ICER) was used to perform the cost effectiveness analysis.
There were 248 patients enrolled in the study. The use of the two upfront, POC test pathways significantly exceeded the primary outcome measure of a 20% reduction in treatment time. In the i-STAT + CBC group, the 31 min. time-saving translated into cost-saving of US$14.96 per patient (IECR 0.27) whereas the 21 min. time-saving in the i-STAT only group only had an additional net cost of US$3.11 per patient (IECR 0.90).
Upfront, POC blood tests can be utilised in the resource-constrained EC to manage patients more efficiently by saving time. This time-saving can, in fact, be more cost effective than traditional EC workflow making it an economically viable option for implementation in LMIC.
The Frequency of Unnecessary Testing in Hospitalized Patients
2018, American Journal of Medicine

View all citing articles on Scopus

: Provide feedback on this article at the journal's Web site, www.annemergmed.com.

: A podcast for this article is available at www.annemergmed.com.

: Supervising editor: Donald M. Yealy, MD

: Author contributions: All authors were involved in the study concept and design, review of the analysis and findings, drafting of the article, and critical revision of the manuscript for important intellectual content. RR, EB, and MLM were responsible for acquiring the data and obtaining institutional review board approval. RD performed the data analysis under the supervision of LSZ and MLM, and all authors had input into the variables considered for the analysis and how it was conducted. RR drafted the article, and all authors contributed substantially to its revision. MLM takes responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This project was supported in part by grant number K01HS017957 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

: Reprints not available from the authors.

: Please see page 90 for the Editor's Capsule Summary of this article.

: Publication date: Available online June 11, 2010.

View full text

Clinical practice of emergency medicine/original researchThe Effect of Triage Diagnostic Standing Orders on Emergency Department Treatment Time

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design

Results

Limitations

Discussion

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Measuring crowding: time for a paradigm shift

Acad Emerg Med

Increasing length of stay among adult visits to US emergency departments, 2001-2005

Acad Emerg Med

The effect of emergency department crowding on clinically oriented outcomes

Acad Emerg Med

Systematic review of emergency department crowding: causes, effects, and solutions

Ann Emerg Med

Crowding delays treatment and lengthens emergency department length of stay, even among high-acuity patients

Ann Emerg Med

The impact of input and output factors on emergency department throughput

Acad Emerg Med

Adding more beds to the emergency department or reducing admitted patient boarding times: which has a more significant influence on emergency department congestion?

Ann Emerg Med

Trends in the rates of radiography use and important diagnoses in emergency department patients with abdominal pain

Med Care

Analysis of factors influencing length of stay in the emergency department

CJEM

Analysis of the literature on emergency department throughput

West J Emerg Med

On-call specialists and higher level of care transfers in California emergency departments

Acad Emerg Med

Consultations in the emergency department: a systematic review of the literature

Emerg Med J

Clinical practice of emergency medicine/original research
The Effect of Triage Diagnostic Standing Orders on Emergency Department Treatment Time