A few years back, a facetious advertisement in the Canadian Journal of Emergency Medicine promoted the availability of fellowship positions in “Waiting Room Medicine”, a comedic take on the struggles of the specialty to manage increasing patient volume with limited resources. While there are certainly Emergency Departments with ample space and “white glove”-type service – see the for-profit expansion of free-standing EDs in states like Texas – there are also publicly-funded and other EDs that struggle with physical bed space for patients for a variety of reasons.
This study attempts to quantify the effect of an intervention utilized by many overburdened or otherwise saturated EDs – starting the initial evaluation in triage with either provider-directed or protocolized orders. At UCLA/Olive-View, all patients presenting to an already-full ED received an initial rapid evaluation by an attending physician or nurse practitioner. During their 10-month study period, non-pregnant adults with abdominal pain were randomized to either receiving initial evaluation orders following this evaluation, or to be returned to the waiting room to await full evaluation at a later time pending bed availability.
There were 1,691 enrolled and randomized, with approximately 10% excluded from analysis mostly because they left the ED before their evaluation was complete. Overall, the initiation of the work-up in triage saved patients approximately a half-hour, on average, of bedded time in the ED. This was reflected by a similar absolute decrease in overall ED length-of-stay. There were a couple other interesting tidbits unique to their execution:
- The most profound difference associated with WR medicine was simply blood and urine testing. While imaging could be ordered up front, it was rarely done.
- Some of the advantages related to the WR blood testing were minimized by ~13% of patients receiving further testing after being bedded in the ED.
- Patients randomized to WR medicine received, on average, a greater number of diagnostics per patient, probably representing resource waste.
So – yes, this probably accurately reflects the impact of orders placed in triage: some wasted resources based on the initial, incomplete evaluation, with a trade-off of potential time savings. The extent to which your system might benefit from a similar set-up is probably related to your level of chronic bed scarcity.
“Initiating Diagnostic Studies on Patients With Abdominal Pain in the Waiting Room Decreases Time Spent in an Emergency Department Bed: A Randomized Controlled Trial”
http://www.annemergmed.com/article/S0196-0644(16)30360-2/abstract