The Effect Of Triage Standing Orders on Emergency Department Treatment Time

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The Effect Of Triage Standing Orders on Emergency
Department Treatment Time

• Rodica Retezar
• MPH Capstone Project
• December 7, 2009
• Capstone Supervisor Melissa McCarthy
• Advisor Scott Zeger

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Outline

• 1. ED Treatment Time and Standing Orders
• 2. Objective
• 3. Methods
• 4. Results
• 5. Limitations
• 6. Conclusions

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ED Treatment Time

• One component of the ED length of stay
• Defined as the time from patient placement into a
  treatment room to his/her disposition
• Impacted by ED diagnostic and treatment processes
  rather than crowding and system factors

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ED Treatment Time

• Processes established by EDs to improve
  operational efficiency
• Observation and Fast Track units
• Changing registration process
• Physician at triage
• Triage Standing Orders

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Triage Standing Orders

• Derived from common clinical guidelines
• Widely used in EDs
• Enables triage nurse to initiate the diagnostic
  process of a patient prior to physician
  evaluation
• Includes labs, x-rays, ECG
• Determined by the chief complaint
• Partial versus Full

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Objective

• To determine the impact of triage standing orders
  on the treatment time of adult ED patients who
  presented with a chief complaint for which triage
  standing orders had been developed.

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Methods

• Retrospective cohort study of patients seen in
  JHBMC ED, with a volume of approximately 57,000
  visits per year, during a 32-month period
  (January 2007 to August 2009)

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Methods

• Patients with one of four chief complaints
  eligible for the study
• Chest pain
• Shortness of Breath
• Abdominal Pain
• Genito-Urinary Complaints

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Methods

• Used the propensity score to match patients with
  and without triage standing orders with respect
  to potential confounders
• A multiple linear regression was performed to
  determine the impact of triage standing orders on
  the median ED treatment time

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Methods

• Compared the median ED treatment time of patients
  with any triage standing orders to that of
  otherwise similar patients with no triage
  standing orders
• Compared the median ED treatment time of patients
  with partial triage standing orders to that of
  otherwise similar patients with full triage
  standing orders

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ResultsFlow Diagram of Study Participants
Total Adult ED Visits 132,589
Other Conditions 93,870
4 Study Conditions 38,719
Left Without Being Seen 2,988
Fast Track 2,005
Patients Waited lt 15 min 18,330
Missing times 208
Patients Waited gt15 min 15,188
Full Triage Standing Orders 3,833
Partial Triage Standing Orders 8,490
Room Orders 2,865
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Frequency Distribution of Patient Characteristics
by Order Status
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Median Treatment Time for Room Orders vs.
Partial/Full Triage Standing Orders
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Median Treatment Time for Partial vs. Full Triage
Standing Orders
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Limitations

• Generalizability
• Not controlled for other factors
• Triage nurse
• Radiological tests
• Consultations
• Not assessed the impact on downstream events

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Conclusions

• First study to assess the impact of triage
  standing orders on ED treatment time
• Triage standing orders in comparison to room
  orders decreased the median ED treatment time by
  15 regardless of the chief complaint

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Conclusions

• Median ED treatment for full triage standing
  orders in comparison to partial ones varied by
  the chief complaint
• Future studies needed to determine which orders
  are important not only for the diagnostic process
  but also to maintain triage efficiency

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References

• 1. Herring A, Wilper A, Himmelstein DU, et al.
  Increasing length of stay among adult visits to
  U.S. Emergency departments, 2001-2005. Acad Emerg
  Med. 200916(7)609-616.
• 2. McCarthy ML, Zeger SL, Ding R, et al. Crowding
  delays treatment and lengthens emergency
  department length of stay, even among high-acuity
  patients. Ann Emerg Med. 200954(4)492-503.
• 3. Zun LS. Analysis of the Literature on
  Emergency Department Throughput. West J Emerg
  Med. 200910104-109.
• 4. American College of Emergency Physicians
  Emergency Medicine Crowding and Boarding -
  Optimizing Emergency Department Front End
  Operations. Available at http//www.acep.org/prac
  tres.aspx?id32050ekmenselc580fa7b_90_202_32050_
  5. Accessed September 30, 2009.
• 5. Mickel J, Reinke D. A Review of Anemia
  Management in the Oncology Setting A Focus on
  Implementing Standing Orders. Clin J Onc Nurs.
  200711(4)534-539.
• 6. Cabana MD, Rand SR, Powe NR, et al. Why Dont
  Physicians Follow Clinical Practice Guidelines?
  A Framework for Improvement. JAMA.
  1999282(15)1458-1465.

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Thank You