The Impact of Involving a Senior Emergency Physician in the Triage Process

Introduction

One of the primary variables tracked in the emergency department (ED) as a proxy measure of timeliness and service quality is the waiting time for consultation [1]. Crowding happens in the ED when the demand for emergency services exceeds the ability to deliver care within an acceptable time period [2]. Overcrowding has been noted in multiple studies and was linked to negative side effects such as longer waiting times, lower patient satisfaction, and, most critically, poor patient outcomes. It was also linked to inadequate and delayed resuscitation in septic patients, delayed analgesia administration, increased mortality in community-acquired pneumonia patients, increased risk of adverse outcomes in patients presenting with chest pain, incorrect medication administration, and overall increase in morbidity and mortality [3-12]. Long waiting times for walk-ins, meanwhile, generate more complaints and patient dissatisfaction than disease management itself, with the majority of difficulties and dissatisfaction arising as a result of real and perceived waiting times before being seen by a doctor. In most hospitals, standard triage entails the patient first registering with the registration clerk, receiving a ticket number, and then waiting to be called into triage. The triage nurse questions the patient about their complaint and past medical history, and then measures their vital signs. Thus, the patient faces an initial wait for triage, a second wait for the consultation room, and, if an X-ray is required, a further wait for treatment and release. How much better would it be if these distinct delays could be

reduced to one or two, especially in simple cases? [13,14].

An area of special interest has been the exploration of the use of advanced providers in triage to aid ED throughput and reduce risk exposure for patients. Numerous organisations have investigated the influence of triage liaison physicians (TLPs) on the Committee on Medicare and Medicaid Services (CMS)’ numerous quality indicators, the most relevant to the emergency department being ED Length of Stay (ED-LOS) and Left Without Being Seen (LWBS). There have been prior systematic reviews and meta-analyses of the influence of TLPs on ED-LOS and LWBS. Those of Rowe et al . and Abdulwahid et al. comprised investigations from various hospital settings in different nations, and the results in both studies were too varied to make decisive conclusions [15,16]. Several investigations are currently underway in the United Kingdom regarding the see-and-treat system. The primary premise of see-and-treat, as supported by the British Association for Accident and Emergency Medicine and the Royal College of Nursing, is allowing the first clinician or practitioner who sees the patient to properly assess, treat, and release those with minor complaints. More than 160 of England's 202 accident and emergency departments are currently testing or implementing some form of see-and-treat system to treat patients with minor illness or injuries [17]. However, widespread adoption of this system and the production of shorter waiting times for treatment, as well as the extra staff requirements (many departments fail to perceive the benefit of placing a senior emergency physician in the triage area and some cannot afford the luxury of doing so), have yet to be fully evaluated; initial reports show some effect, while others have said that it creates a major drain on senior physicians by taking them away from front- line cases. Healthcare workers, on the other hand, report higher morale when waiting rooms are emptier, even if the number of patients has not decreased [17]. To the best of our knowledge, no systematic review has explicitly investigated the effectiveness of incorporating a senior physician into a triage system to alleviate the consequences of ED overcrowding. Despite nurse triage being widely adopted as the

standard strategy in most hospitals globally, there is mounting concern among policymakers regarding its adequacy in addressing the escalating issue of ED crowding worldwide [18]. The impact of introducing seniors into triage remains largely unexplored in international literature, and no research has been conducted on this topic within Saudi Arabia. As indicated above, we set out to assess whether patient triage undertaken by senior emergency physicians would reduce the waiting time, door-to- decision time, and door-to-doctor time, as well as improve patient satisfaction throughout the emergency department.

Materials and Methods

Study Design and Setting:

This was an interventional pre-post study that utilised retrospective data to evaluate the effect on ED throughput of triage by senior emergency physicians.

The study was conducted at the adult emergency department of the tertiary hospital of a large medical city, with an annual ED visit volume of approximately 57,700, and received the Institutional Review Board (IRB) approval number 23-476. We hypothesise that assigning an emergency consultant to the triage unit will reduce waiting times, shorten the time to initial physician contact and diagnostic testing, and increase patient satisfaction.

Intervention:

The introduction of an emergency consultant as a triage strategy was initiated on January 1, 2023. Our study timeline included the period from Quarter 4, 2021 to Quarter 2, 2023. Upon initiation of the project, an attending emergency consultant was present in the triage unit seven days a week, over two eight-hour shifts per day: from 10:00 a.m. to 6:00 p.m. and from 6:00 p.m. to 2:00 a.m. The time frame for these shifts was extrapolated from previous data that measured peak ED crowding times. It was the duty of the emergency consultant to assess patients after initial evaluation by the triage nurse, and then to allocate and re-direct them to the appropriate areas (either the main section of the ED or the fast track for definitive treatment and completion of diagnostic workup), recognising any life-threatening conditions and meeting patients’

needs, discussing their concerns, and explaining their conditions to increase patient satisfaction. The position of triage physician was an additional post to the existing staffing model.

Study Period:

All patients presenting to the ED from Quarter 4, 2021 to Quarter 2, 2023 were eligible for inclusion in the study. We extended our investigation back to the last quarter of 2021 to better capture the changes in the triage model and to reduce variabilities that may represent confounders.

Data Collection:

Data were collected using a survey conducted by a third party. This survey is known as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and is a valid and reliable tool that identifies and measures essential components of patient-centredness and engagement, used in a variety of settings such as inpatient, medical practice clinics, and home health care. The CAHPS survey examines the frequency of certain healthcare delivery behaviours such as communication, responsiveness, discharge instructions, etc. [19] To study the effect of physician triage on the entire day, rather than a 16-hour period, data from the entire 24-hour day were analysed.

Data Analysis:

Our study utilised Stata Version 17 as the data analysis software. The variables recorded were: door- to-doctor time (arrival to first provider), door-to- decision time (admit or discharge), waiting time (door to room), patient satisfaction scores (quantitative) and various aspects of patient experience and perception (qualitative).

Quantitative Variables:

Door-to-doctor time, door-to-decision time, waiting time and patient satisfaction scores through the use of a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey tool, were all presented as average times and scores before and after the intervention.

Qualitative Variables:

Qualitative variables related to patient satisfaction and experience were presented using a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey tool. We calculated the average times and scores of the participants’ answers, both before and after the intervention.

Results

A total of 2566 patients were enrolled in the study. The average door-to-decision time decreased by almost 45 minutes, as shown in Table 1, suggesting expedited treatment decisions for both admitted and discharged patients. Additionally, post-intervention surveys (Table 2) revealed an increase in patient- perceived comfort in the waiting area, courtesy of nurses, overall care ratings, and likelihood of recommending the emergency department. The line graph in Figure 1 demonstrates the shifts in patient perception across various healthcare interactions before and after the intervention; the graph tracks several key areas of change in patient experience, notably the waiting time before being brought to the treatment area. Other noteworthy, though smaller, improvements include nurses’ attention to needs, doctors’ concern for patient comfort, and overall ED cleanliness. Interestingly, despite efforts to improve waiting times, there was a slight increase in the average door-to-room time post-intervention.

Discussion

The concept of doctor triage is not new. Napoleon Bonaparte’s head surgeon, Baron Dominique Jean Larrey, was described as the first to perform triage on the battlefield [20]. Recent research has addressed the subject of triage, with the common goal of improving service by lowering waiting or processing times [21]. In the study by Jin et al. , a moderate improvement in ED length of stay was observed. However, they studied the effect of senior physician triage during only one shift per day, from 1:00 PM to 9:00 PM, over

9-week period. Their study was conducted in a Level I trauma centre, and their baseline mean length of stay was 266 minutes [22]. Partovi et al . performed a similar intervention in a county-owned university hospital in the U.S. and found that ED length of stay was reduced by a mean of 82 minutes (p= 0.005) [23]. In the present study, the introduction of a senior emergency physician to the triage system saw a nuanced effect on both patient experience and operational metrics. While we observed a modest decrease in admission and discharge time, the waiting time before being roomed increased. With regard to

the time from arrival to first provider, there was no significant difference between the pre-intervention and post-intervention periods. Patient satisfaction improved in specific areas, notably the perception of waiting area comfort, nurse attentiveness, and overall care received. This, coupled with an increased willingness to recommend the ED, aligns with a heightened sense of care and connection from the patient’s perspective. Small declines were noted in perceived physician courtesy and concern for patient comfort – potential consequences of higher physician workload or the need to streamline processes. Interestingly, these declines occurred despite improved overall care ratings, underscoring the importance of examining qualitative patient feedback. It appears that patients may value the expertise and authority of a senior physician, leading to greater satisfaction, even at the expense of some aspects of personalised care. Interestingly, some others’ findings contradict prior research that suggests a consistent reduction in waiting times with physician-led triage [24, 25]. Our study’s increase in initial waiting times may be an outlier. Furthermore, while Rowe et al . identified significant heterogeneity in outcomes across studies, our observed dip in physician courtesy and patient involvement scores is also unusual [24]. A possible explanation is that senior physicians focusing on rapid triage assessment might unintentionally sacrifice elements of bedside manner in prioritising efficient patient sorting. However, the increases in overall care ratings and likelihood of recommending the ED indicate improved satisfaction despite certain changes in patient-physician dynamics. This highlights the need for nuanced studies exploring how differing triage models balance timeliness with the patient- centredness of interactions. This study has some limitations. Due to the interventional pre-post study design, there is a risk that outcomes may have been influenced by confounding variables such as seasonality, staff morale, or other initiatives that may have played a role alongside the triage adaptation. Additionally, the study only examined a triage model involving a part- time senior physician, leaving the impact of full-scale implementation uncertain. Additionally, patient

feedback, while valuable, carries inherent subjectivity. Lastly, a lack of process analysis obscures whether the senior physician modified the triage decision-making itself, which would have impacted resource allocation and contributed to the changes observed. The findings of this study warrant further exploration to optimise the impact of senior physician-led triage. Future research should investigate extended periods of physician cover, conduct multi-site studies for broader insights, and analyse the reasons behind heterogeneous wait time trends. It should also incorporate structured qualitative feedback from patients and providers to understand complex perception changes, and consider refined study designs (e.g., randomised controlled trials) for stronger causal inference. Such investigations, along with ethical and cost-effectiveness analyses, are crucial in order to tailor senior physician-led triage models for maximum benefit to patient experience and emergency department efficiency.

Conclusion

The integration of a senior emergency physician into the triage system shows promise in improving patient satisfaction and streamlining operations. It is crucial to address the issues raised while acknowledging the complexity of such intervention. The reduction in door-to-decision times is an important result, while other effects of the intervention suggest that process adjustments may be necessary for optimal results. The mixed outcomes point toward an impactful, yet iterative, process of optimising patient flow and experience in the ED with senior physician triage. Further research is essential to refine the integration process for improved results in this specific ED, as well as for wider application in other settings.