At St. Elizabeth Youngstown (OH) Hospital, ED providers noticed an uptick in patients who left without being seen (LWBS). “We were concerned that many patients would leave without being triaged or evaluated, and could have potentially poor outcomes,” says Chad Donley, MD, program director and chairman for the department of emergency medicine.
The ED added an advanced practice provider at triage to evaluate patients, in conjunction with a standard nurse triage. “This helps identify some of the more subtle presentations of certain disease states,” Donley says.
The provider is more likely to consider obscure diagnoses, such as epidural abscess or pulmonary emboli. “We had hoped that we could help identify those patients who were more ‘silently ill’ who would be difficult to pick up simply by ED nurse triage,” Donley explains.
The new triage process possibly saved the life of a young patient with a chief complaint of anxiety. “One of our advanced practice providers was astute enough to identify an unusual aortic murmur, and quickly facilitated the workup,” Donley recalls. An aortic dissection was diagnosed, leading to a life-saving emergency surgery that may not have been picked up with the standard triage process.
As a result of the new triage process, the ED’s LWBS rate decreased from 5% to 1%, according to an analysis of 2,162 patients who LWBS from 2013-2017.1 Patients who left the ED without seeing the provider at triage decreased by 69%. However, patients who were seen initially, but left the ED without completing treatment, decreased by only 39%. This meant a number of patients still were LWBS even though they had been seen by a provider, and might have undergone lab work or testing.
Donley and colleagues were surprised so many patients still ended up leaving the ED — most of the time, without telling anyone. “We anticipated that by having blood work drawn and imaging testing performed that many more — closer to 90% — would stay,” Donley says.
Even so, ED providers believe by testing faster, they can identify potentially life-threatening conditions sooner. “Ultimately, we are still responsible for any patient in the ED waiting room or on the premises,” Donley emphasizes. “Early identification of potential critical illness is key.”
To combat high LWBS rates of 7%, Springfield, MA-based Baystate Medical Center added an EP at triage. The biggest concern was too many high-risk patients were walking out of the ED because of long waits. “We had a lot of ESI [Emergency Severity Index] Level 2s waiting too long to be seen who had negative consequences in terms of delays in care,” says Niels Rathlev, MD, chair of the department of emergency medicine at the University of Massachusetts Medical School-Baystate.
The ED used a fast-track system through which lower-risk patients could be seen (ESI Levels 3, 4, and 5), but only on weekdays. “Like just about any other ED, we have a shortage of nursing care and techs. We had providers to do that kind of service for ESI 3s, 4s, and 5s. But we didn’t have the ability to do that every single day,” Rathlev reports.
The ED decided to shift the focus toward assessing the high-risk Level 2s faster. If there are no Level 2 patients in the waiting room, providers then focus on the Level 3s. “In terms of safety and patient care, it really made sense to work down from the top and focus on the most acute patients, as opposed to focusing on the 4s and 5s,” Rathlev says.
Staffing the triage program with techs and nurses has been a challenge. Currently, the process is used from 11 a.m. to 7 p.m. on weekdays. “We would love to do it 24/7. But we would certainly need more nursing and tech staff to do that,” Rathlev notes. “To be able to do it in the middle of the night, we would certainly need more provider staff as well.”
No additional staff have been added for the physician triage program. Instead, the fast-track providers were brought in for eight-hour shifts at triage. “We also have a swing doctor who takes care of all the major traumas and resuscitations, and helps wherever they can. We converted that role and put them up front,” Rathlev says.
At triage, providers are working with limited information — usually, only a history and physical exam to assess how worried they are about the patient. “You ideally want your most experienced doctors who are the best at diagnostics,” Rathlev says.
Physicians have caught some Level 2s who deteriorated in the waiting room. One diabetic patient presented with high blood sugar and was triaged as Level 2. The physician recognized the patient was going into diabetic ketoacidosis, and care was instituted sooner than previously would have been the case.
Another case involved an older patient who presented with abdominal pain and eventually developed fever and tachycardia. As it turned out, this patient’s condition was serious. Other Level 2s reported chest pain, even though the ECG was normal and the cardiac troponin level was negative. However, the second troponin was either positive or indeterminate.
In a few cases, the patients were ruled in for acute coronary syndrome or a non-ST-elevation myocardial infarction. Without the physician at triage, these patients may have had to wait several hours for intervention. In theory, this could have been life-threatening.
Initially, not all ED staff bought into the new triage process. “It required quite a bit of ‘human engineering,’ if you will, to be able to do this,” Rathlev says.
Nurses, technicians, the hospital’s operational excellence team, and ED providers met for three days to hammer out the details on how physician triage would be implemented. Some were concerned that giving a rapid medical evaluation to patients up front exposed ED providers to more legal risks compared with the previous process (i.e., patients staying in the waiting room until they were brought back for an EP evaluation).
“That was the perception, and something we’ve had to work to overcome,” Rathlev says. “We are focusing on helping people, and the medical/legal risk comes secondary to that. That is really a cultural and philosophical argument.”
It is impossible to know with certainty how putting a physician at triage will affect ED malpractice claims. “But we all have to be on the same page with respect to what we are trying to do,” Rathlev says. “Job No. 1 is quality and safety. As long as we focus on quality and safety, that will lead to lower medical/legal risk.”
The ED’s goal is shorter length-of-stay times for patients who are discharged. For patients who are admitted, “boarding still plays a large role, and [the new triage process] probably doesn’t change length of stay,” Rathlev says.
Total LWBS rates might not change, either, since prioritizing Level 2s means Level 4s and 5s are waiting longer. “But the advantage is fewer of the Level 2s are LWBS. We don’t want anyone to walk out,” Rathlev adds. “But if we had a choice, we would prefer a Level 5 to walk out rather than a Level 2.”
- Sember M, Donley C, Eggleston M. Implementation of a provider in triage and its effect on left without being seen rate at a community trauma center. Open Access Emerg Med 2021;13:137-141.