When to Use Provider Triage in Emergency Departments

Nobody likes to wait, especially when suffering from a potentially life-threatening condition that requires immediate intervention. Yet millions of patients face this fate even in the most developed countries. Across the 145.6 million annual Emergency Department (ED) visits in the US, patients wait on average 2.25 hours, and even patients with broken bones wait an excruciating 50 minutes on average before they are given any pain medication. Perhaps more worryingly, close to 2% of the patients leave the ED because of long wait times before getting any treatment.

Hospitals try to tackle the problem of ED crowding using various approaches. However, each comes with additional costs to hospitals that are already under significant financial burden. Any practical approach to alleviating ED crowding must therefore be informed by the financial consequences in addition to increasing quality of care.

In their paper “When to Use Provider Triage in Emergency Departments”, Kamali, Tezcan, and Yildiz, analyze the process flow and economic implications of one increasingly common intervention to alleviate ED crowding, namely provider triage (PT). Traditionally, triage is conducted by one or more nurses in a method known as nurse triage (NT). When patients arrive in the ED, they are usually triaged within a few minutes by a triage nurse, who interviews the patient and records her medical history and complaints. An alternative triage method is PT, where triage is conducted by a provider in addition to a nurse. The triage provider performs a brief initial assessment or medical screening examination and initiates diagnostic testing and treatment in the triage area when necessary.

When PT is used, the patient is seen by a provider for the first time at the triage stage instead of the treatment stage as in NT, and patients with only minor complaints (in our data set 18% of patients, reported to be as high as 30% in other EDs) can be discharged after the initial evaluation in the triage area. Also, a triage provider is authorized to order a number of additional tests that a triage nurse cannot order. This potentially leads to more diagnostic tests being ordered during PT and fewer tests needed in treatment rooms. As a result, a patient would spend less time in a treatment bed, which is one of the major bottlenecks in EDs. However, PT is not free. Staffing costs may increase under PT because of potential changes in the ED staffing level. In addition, because the provider may start the treatment of a patient during triage and the hospital may not be fully reimbursed by the healthcare payer for the cost of treatment if the patient abandons the ED, the cost of a patient who leaves before being taken to the treatment area may be higher under PT. Therefore, hospitals need to carefully choose when to apply this alternative triage method.

In their study, the authors provide insights into when to apply PT in an ED based on economic considerations and propose an easy-to-implement heuristic that can be obtained with back-of-the-envelope calculations. The analysis of their mathematical model shows that, NT or PT may be preferred depending on the arrival rate at the ED. Generally speaking, NT always outperforms PT when the arrival rate is sufficiently low, but PT can outperform NT as the arrival rate increases. Interestingly, when the arrival rate becomes sufficiently high, NT may be preferred once again because of the potentially higher abandonment cost per patient under the PT method or limited PT capacity. This perhaps unintuitive result is valuable for practitioners as currently the general practice is to deploy PT when the patient volume is high.

The authors also test the performance of their proposed policy by using operational data collected from the ED of a large urban teaching hospital. The results indicate that the performance of their approximation-based solution method is remarkably close to that of the best solution obtained via simulation (0.32% decrease in the objective on average). They also find that utilizing PT and NT effectively could benefit the ED economically by as much as 10%. Therefore, a carefully designed triage method not only helps improve patient flow but also provides significant economic benefits to hospitals and can be a win-win scenario both for patients and EDs.

Read the full article at https://doi.org/10.1287/mnsc.2017.2982.

REFERENCE

Kamali M, Tezcan T, Yildiz, O (2019). When to Use Provider Triage in Emergency Departments. Management Science 65(3):1003–1019.

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