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| Journal of the New Zealand Medical Association,
02-July-2002, Vol 115 No 1157
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Effect of a rapid assessment clinic on the waiting time to be
seen by a doctor and the time spent in the department, for patients presenting
to an urban emergency department: a controlled prospective trial
MW Ardagh, J Elisabeth Wells, Katherine Cooper, Rosa Lyons,
Rosemary Patterson, Paul O’Donovan.
The setting for this study was the Emergency Department (ED)
of Christchurch Hospital, Christchurch. It is the only ED in the city, servicing
a population of approximately 400 000 people and attending to more than 65 000
patient presentations per annum. It sees patients across the whole breadth of
emergency medicine and the medical staff consist of a mix of fellows of the
Australasian College for Emergency Medicine, registrars and senior house
officers. It is staffed by approximately 65 full time equivalent emergency
nurses. All patients are triaged at point of arrival by an emergency nurse
trained in triage and according to the triage scale of the Australasian College
for Emergency Medicine.1 One of the key
performance indicators of the ED is the waiting time for patients of each triage
category to be seen by a member of the medical staff.
The efficient functioning of a busy ED relies on the ability
to maintain patient flow, so that patients are moved on to the next phase of
their care in a timely fashion and consequently new patients can take their
place in the treatment area. Two barriers to efficient patient flow are at point
of entry to, and point of exit from, the ED.
At point of entry, patients undergo triage primarily to
determine urgency for care. Those triaged as most urgent will be seen by a
doctor before those triaged as less urgent. The waiting time to see a doctor
will be determined by a number of factors, but particularly the medical resource
available, the nursing resource, and the physical space available to accommodate
the patient for medical assessment, as well as the number of patients waiting
and their mix of urgency as determined by the triage process.
Once seen by a doctor, the barrier to moving to the next
phase of care is also contributed to by a variety of factors, including
difficulty accessing a hospital bed, but also difficulties in decision making
manifest by ongoing investigations and assessment of the patient.
The authors recognised that a proportion of patients
presenting to an ED required little or no decision making, as their needs were
readily apparent. However these patients are not identified by the triage
process, which purely identifies urgency for care, rather than a capacity to be
managed quickly. Indeed these patients would frequently wait for medical
attention in a treatment area, thereby denying the treatment area for patients
waiting in the waiting rooms or in corridors.
The aim of this study was to introduce another dimension to
triage, the rapid assessment clinic (RAC), to determine if this would reduce the
waiting times and times in the department for all patients.
MethodsFor ten weeks from
28th February 2000, an additional nurse and an
additional ED registrar were rostered a 0900 to 1700hr shift Monday to Friday.
On the odd weeks, these two staff ran a RAC and on even weeks, they did not run
a RAC, but simply joined the other medical and nursing staff, managing patients
in the traditional way. A total of two nurses and five emergency medicine
registrars were rostered to RAC duties. The RAC was held in the same two
adjacent cubicles for the duration of the study.
From 0900 to 1700hr Monday to Friday during the odd weeks, the triage nurse would identify patients who could be managed in the RAC. During the even weeks, patients would be triaged in the usual way, without identifying those suitable for rapid assessment. Patients suitable for the RAC were those for whom disposal was readily apparent, interventions required were quickly undertaken, and lengthy investigations or assessment were not required. Suitability for the RAC was independent of triage category and although it tended to include a disproportionate number of lower triage category patients, no triage category was exempt. A list of patients suitable for the RAC was provided to the triage nurses (Table 1). After the ten-week period the five weeks of the RAC and the five weeks with no RAC, but the same staffing level, were analysed and compared, using the week as the unit of analysis, which is a conservative analytic strategy. The RAC weeks and the control weeks were compared for total patient presentations to the ED, the waiting time to be seen by a doctor and the length of time in the department. Data for those who went through the RAC clinic were not specifically analysed, but instead data were analysed for all patients in the department. The reason for this was that it would be easy to show that those patients put through a RAC are seen rapidly and dispatched promptly, but it was the purpose of this study to determine if the RAC improved patient flow for the department overall. In addition, prospectively identifying ‘rapid assessment type’ patients during the control weeks would have altered the way they were managed by ‘flagging’ them as quick patients. Table 1. Patients suitable for the rapid assessment
clinic.
NB: Any patients, after medical assessment, who needed
more thorough ED assessment or treatment would be referred to another part of
the ED for management by doctors and nurses who are not running the rapid
assessment clinic.
For each week the mean times were calculated, thus producing
five replicates for the RAC period and five for the non-RAC period. There was a
considerable amount of missing data for the time to see a doctor and this was
mostly due to a number of patients who left the department without seeing a
doctor (nurse initiated referrals to Orthopaedic Outpatients or the
Children’s Acute Assessment Area, or patients who did not wait to be
seen). There were no missing values in the length of time in the department but
there were a number of extreme outliers which were thought to result from staff
recording disposal subsequent to the event. Because of the skew in both time
variables and because of the outliers the median was also calculated for each
week which produced a very similar pattern of results to that obtained from the
weekly means.
The raw data were extracted from the ED module of PMS, the
Patient Management System used at Christchurch Hospital. Analysis was carried
out in SAS using PROC FREQ and PROC
TTEST2.
ResultsDuring the five weeks of the RAC
clinic (0900 to 1700hr Monday to Friday) a total of 2263 patients attended the
ED, and 361 of these were referred to the RAC clinic. Of the 361 patients
managed in the RAC there were 235 males and 126 female patients and their age
distribution and presentation by weeks of the trial are given in Table 2. A list
of their presenting problems is given in Table 3.
Table 2. Age range and number of patients seen in the
rapid assessment clinic.
Table 3. Presenting
problems and the number of patients who presented to the rapid assessment
clinic.
During the five control weeks (0900 to 1700hr Monday to
Friday) a total of 2204 patients attended the ED, and a retrospective review of
presenting complaints undertaken by the authors identified 349 patients who
would most likely have been triaged to the RAC, had it been running.
Table 4. Triage category breakdown for all patients
presenting during the RAC (study) and non–RAC (control) periods and
comparison with RAC–only patients.
* One patient coded as Triage=0. (RAC-only patients are
those managed in the RAC). RAC = rapid assessment clinic.
A comparison of the triage category breakdown for all
patients presenting during the RAC periods and during the non-RAC (control)
periods, and for patients managed in the RAC is given in Table 4. Combining over
weeks, there was no significant difference in the distribution across triage
categories between the RAC and non-RAC periods
(χ2=3.1, df=4, p=0.53).
Table 5. A comparison of
average waiting time (in minutes) to see a doctor, by triage category, for RAC
and non-RAC periods (sd across weeks given in brackets).
*See Methods. RAC =
rapid assessment clinic.
The waiting times to be seen by a doctor are outlined in
Table 5, which compares the RAC and the non-RAC (control) periods within each
triage category. Each summary measure has been averaged over the five relevant
weeks. The pattern of results is for no difference at Triage 2 and 3 categories
and a difference of several minutes for Triage 4 and 5 categories. These results
cannot be attributed to different amounts of missing data as 10.8% of times were
missing in both the RAC and non-RAC periods.
The times patients spent in the ED are shown in Table 6 for
RAC and non-RAC periods. Note that time in the department includes time
undertaking imaging in the Department of Radiology. The pattern of results is
similar to that for time to be seen by a doctor, with no difference for Triage 2
and 3 and about 20 to 25 minutes advantage for RAC-week patients in Triage
categories 4 and 5. However because of the extreme variability in length of time
in the department these differences are not precisely estimated, especially for
Triage category 5 which had only a sixth as many patients as Triage category
4.
Table 6. Average time in department (in minutes) by
triage category, for all patients presenting during RAC and non-RAC periods (sd
across weeks given in brackets).
*No missing data
– see Methods
DiscussionThe purpose of this study was to
determine the value of a RAC in improving patient flow in an ED. The five RAC
periods and the five control periods showed a similar number and triage profile
of patients presenting, although it was also noted that average waiting times
were not long. This is a reflection of the fact that the trial was undertaken at
the department’s least busy time. A previous study of patient
presentations to Christchurch Hospital ED showed that winter and evenings had a
consistently higher workload than summer and daytime, and that the weekends
attracted a greater proportion of patients suitable for RAC management than
weekdays3. Given the small proportion of
patients going through the RAC and the paucity of barriers to patient flow
during the quiet time of the study, this study will struggle to show a benefit
to the department for a RAC. However despite this, the RAC did bring a reduction
in waiting time to see a doctor, and time in department for the lower triage
categories.
These findings confirm that the rapid management of patients
with problems which do not require prolonged assessment or decision making, is
not only beneficial to those patients, but also to other patients sharing the
same, limited resources. The value of a RAC is likely to be much greater in the
evenings, weekends and wintertime and this will be the subject of further
study.
Author Information:
MW Ardagh, Professor of Emergency Medicine; J Elisabeth Wells,
Biostatistician, Christchurch School of Medicine and Health Sciences; Katherine
Cooper, Registered Nurse; Rosa Lyons, Clinical Nurse Specialist; Rosemary
Patterson, Registered Nurse; Paul O’Donovan, Clinical Charge Nurse.
Emergency Department, Christchurch Hospital, Christchurch.
Correspondence: M W
Ardagh, C/- Emergency Department, Christchurch Hospital, Private Bag 4710,
Christchurch. Fax: (03) 364 0286; email: michael.ardagh@cdhb.govt.nz.
References:
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