Introduction: Physician Initial Assessment (PIA) time at the Montfort Emergency Department (ED) in Ottawa is one of the longest in the province. PIA, Length of Stay (LOS), and Left Without Being Seen (LWBS) are all performance measures which impact hospital funding through the pay for results (P4R) system. Increased PIA times negatively impact hospital funding, patient satisfaction and may be correlated to patient safety. Our aim was to examine whether having a physician at triage during the last hour of their shift decreased PIA time, LOS, and LWBS rate, and also to overall improve patient care received in the Emergency Department. 

Methods: During the last hour of five different Emergency Department (ED) shifts (14-15h, 16-17h, 19-20h, 22-23h, 23h-00h), the physician worked with a designated registered nurse, evaluating patients in a room adjacent to triage and the waiting room. The current study evaluated the effectiveness of having a physician perform initial assessments at triage (including history, physical and ECG) and assess the impact on PIA time, LOS, and LWBS during the specific hours that a physician is at triage. This is a pre-post retrospective study. Baseline data was collected retrospectively over a period of 20 weeks prior to the intervention (between January 2017 and June 2017). Intervention data was collected over a period of 20 weeks starting in June 2017. Statistical process control (SPC) methodologies were then applied to the pre-post data of continuous variables. PIA time and LOS averages were obtained for each hour in which the physician was stationed at triage. I (XmR) charts were used for statistical analysis. Analysis was done using QI macros in Microsoft Excel. 

Results: Reductions in PIA times of 8 minutes (14-15h), 16 minutes (16-17h), 30 minutes (19-20h), 72 minutes (22-23h) and 88 minutes (23h-00h) were demonstrated across the 5 shifts throughout the trial period. No clear increase in LWBS wait times were demonstrated. Overall ED volumes increased modestly over the course of the intervention. Overall ED LOS in the department decreased about 25 minutes over this same period. There were no other PIA or LOS reduction initiatives taking place in the ED over the trial period. 

Conclusion: The goal of this study was to have patients seen quickly by an emergency physician at triage who would perform a rapid initial assessment and respond to needs for pain management, and order urgent testing or imaging. In this study, PIA times improved after the process change for every time period tested. One possible limitation was that this intervention likely had less adherence at the beginning of the trial as the staff adjusted to the new shift flow. This seems to be reflected in the data, since an improved process change is demonstrated near the end of the trial period. The next step in quality care improvement is to look at lab and imaging data to evaluate the utilization of tests with a physician at triage.

Authors: J.A. Bostwick, S. Visser, S. Mondoux