A physician-nurse team adjacent to triage shortens length of stay and left-without-being-seen rates
Article information
Abstract
Objective
Staffing significantly influences emergency department (ED) throughput; however, there is a shortage of registered nurses (RNs), impacting ED flow and crowding. Non-RN providers, like licensed practical nurses (LPNs), could potentially assist with tasks traditionally assigned to RNs. To improve the front-end ED process, we implemented an attending physician–LPN team (PNT) positioned next to triage and utilized existing ED hallway space.
Methods
This study took place at a tertiary care ED with over 110,000 annual visits. We compared postintervention (post-PNT) data (November 1, 2022–February 28, 2023) to preintervention (pre-PNT) data (July 31, 2022–October 31, 2022). The PNT, positioned adjacent to triage, expedited care for ED patients awaiting open rooms. The PNT selected patients from the waiting room to bypass the main ED, evaluated them in a private room, and then moved them to the hallway pending further care. Multivariable regression analysis was utilized to measure the impact of different factors on ED length of stay (LOS).
Results
We analyzed 23,516 patient visits, 10,288 in the pre-PNT period and 13,288 in the post-PNT period. Post-PNT consisted of 2,454 PNT visits and 10,834 non-PNT visits. The intervention led to significant improvements, including a decrease in mean ED LOS from 492 to 425 minutes, a decrease in 72-hour revisits from 5.1% to 4.0%, a decrease in left-without-being-seen rate from 6.7% to 3.3%, and a decrease in the mean arrival-to-provider time from 74 to 60 minutes. Multivariable regression analysis showed that ED LOS was significantly lower for post-PNT patients than pre-PNT.
Conclusion
By leveraging the scope of LPNs and utilizing existing ED space, the PNT model successfully reduced front-end bottlenecks, leading to improved throughput and reduced revisitation and left-without-being-seen rates.
INTRODUCTION
There are over 131 million emergency department (ED) visits annually in the United States [1]. Over 90% of EDs face crowding [2] and many are stressed every day. ED crowding results in delays in care[3,4], increased errors [5], increased inpatient mortality [6], and decreased patient satisfaction [7]. Additionally, crowding increases ED length of stay (LOS) [8] and left-without-being-seen (LWBS) rates [9,10]. This study addresses the urgent need to incorporate workflows to reduce ED crowding and improve LOS and LWBS measures.
Staffing strongly impacts ED workflows and the volume of patients that can be cared for. However, there is a nationwide shortage of registered nurses (RNs) [11] impacting ED nursing staffing. Decreased RN staffing further negatively impacts ED crowding and throughput [12]. Given the shortage of RNs, non-RN providers can assist with some tasks traditionally assigned to emergency RNs, thereby aiding in ED throughput [13]. Licensed practical nurses (LPNs) are able to help with some ED workflows. LPNs can assist with certain tasks, such as placing intravenous lines (IVs), blood draws, and limited medication administration, per local state and hospital regulations.
To reduce crowding and improve throughput, many EDs have attempted initiatives such as redesigning the front-end [14], incorporating providers in triage [15], direct bedding [16], registration at bedside [17], split flow [18], and bed expansion [19]. Although there has not been one initiative that has been found to work best, success is likely dependent on multiple factors including the ED characteristics, staffing, and patient population. In the current landscape with limited ED space and RN staffing, there is a great need for a process where patients can be cared for by utilizing current space without adding beds/rooms or requiring additional RN staff.
At our institution, we implemented an attending physician–LPN team (PNT) and positioned them adjacent to triage to expedite the care of ED patients waiting for open rooms in the main ED. The PNT chooses patients directly from the waiting room to bypass the main ED, evaluates them in a private room, and then moves them to the hallway pending labs, imaging, and medications. Patients are reevaluated and dispositioned by the PNT without ever being assigned a room.
The objective of this investigation was to describe a PNT positioned adjacent to triage that cares for patients without assigning rooms and to evaluate and report how the implementation of the PNT impacted patients seen per hour, LOS, LWBS rate, arrival-to-provider time, and 72-hour revisits.
METHODS
Ethics statement
This study was approved by the Institutional Review Board of Stony Brook University (No. 2023-00111). Given the minimal risk, informed consent was waived. Our study followed the STROBE (Strengthening of the Reporting of Observational Studies in Epidemiology) reporting guidelines for cross-sectional studies [20].
Study design
This was a single-site, before-and-after study analyzing routinely gathered ED operations and throughput data. The PNT initiative and the data gathered were part of ED quality assurance and quality improvement efforts.
Study setting
Our hospital is a large, suburban, academic, tertiary care center. The annual ED volume exceeds 110,000 visits, of which 74% are adults. The ED has 136 treatment spaces, including 76 rooms and 60 non-room hallway bed spaces. The ED is split into one pediatric treatment area and several adult treatment areas, including two acute care zones and one critical care zone. In the adult treatment areas, there are 129 hours of attending emergency medicine physician coverage, providing 100% coverage of the ED. The ED also has an Accreditation Council for a Graduate Medical Education-Accredited Training Program with 48 residents. The attending physicians supervise 135 hours of resident physician coverage and 72 hours of advanced practice provider coverage per day.
Selection of participants
ED patient encounter data were collected from the Cerner (North Kansas City, MO, USA) electronic health record system. Data from the PNT initiative period (November 1, 2022 to February 28, 2023) and the immediate period before the PNT initiative (July 31, 2022 to October 31, 2022) were extracted from the electronic health record database. These periods were chosen close together to minimize temporal variability. Since the PNT cared for adult, noncritical care, and nongeriatric patients, we excluded pediatric and critical care patients, and adults aged 65 years and older in the comparison groups from both periods.
Interventions
All patients who arrive in the ED go through nurse triage, where they are asked about their chief complaint, have their vitals taken, and are assigned an Emergency Severity Index (ESI). Prior to the PNT initiative, all patients were placed in the waiting area after triage and waited for a room to open in the main ED treatment areas. Once a room became available, the patient was then assigned a nurse and attending physician for their care.
The PNT initiative was created to expedite the care of ED patients waiting for open exam rooms by utilizing a team-based approach to evaluate and manage patients without assigning them to a dedicated room. Due to the RN shortage, LPNs were integrated into the PNT. At our institution, the LPN scope of practice includes placement of IVs, blood draws, and limited medication administration. Leadership RNs covering the ED or the attending physician assist LPNs with tasks outside their scope. For the last several years, LPNs, along with RNs, have cared for patients in our ED acute treatment areas.
The PNT is positioned adjacent to triage, and the triage nurse or PNT team selects patients directly from the waiting room. Patients are evaluated in a private room and then moved back to a hallway pending labs, imaging, and medications. Patients are reevaluated and dispositioned without ever being assigned a room. The PNT private examination room is adjacent to the triage room, and the PNT hallway spaces are also adjacent to the triage room (Fig. 1). The PNT providers are positioned in the hallway next to the patients. The PNT has mobile computers with dictation software (Nuance Dragon, Nuance Communications), a printer, and mobile procedure supply carts in the hallway. There is a stretcher in the PNT private room and chairs in the PNT hallway.
Layout of the emergency department (ED), showing attending physician–licensed practical nurse (PNT) location.
During weekdays, the PNT operates from 8 AM to midnight, and on weekends, it is open 11 AM to 7 PM. The PNT is staffed by one LPN along with one attending physician. No changes were made to the total staffing levels of the advanced practice provider or RN staffing to create the PNT. The attending physician coverage for the PNT was achieved by reassigning the clinical decision unit attending physicians to the new shift. As a result, patients placed under ED observation continued to be covered by the main ED physician who placed them under observation status.
The flow of patient care in the PNT model is outlined in Fig. 2. Patients who present by ambulance are directly brought to the acute or critical care treatment areas. Patients who self-present to the ED are greeted by an emergency medical services team member who performs a pre-registration (name, date of birth, and chief complaint). The patient is then triaged. Patients who have signs or symptoms of a critical condition (e.g., stroke, heart attack, or critical vital signs) are immediately placed in the critical care treatment area. All other patients are brought to the waiting room.
Overview of the patient flow in the attending physician–licensed practical nurse (PNT) model. ED, emergency department; EMS, emergency medical services.
The PNT selects patients directly from the waiting room based on clinical judgment, after assessing that they can be cared for in a hallway, are likely to be discharged after their ED workup, and do not require a stretcher or continuous cardiac monitoring. For patients with ESI levels 2 to 5 (ESI level 1 patients are directed to the critical care zone), the team manages all chief complaints, all dispositions, and can perform all necessary procedures. Additionally, all labs and imaging studies can be conducted for PNT patients. Positioned in the hallway next to the patients, the PNT provides acute care for patients typically sicker than those in a fast-track zone, including higher acuity patients who do not require a stretcher or cardiac monitoring. This setup ensures that all patients are visible to the team and are reevaluated as needed for their workup. While there is no set limit to the number of patients the PNT can care for, there are typically eight to ten active patients at any given time. Patients who remain in the waiting room are transferred to the main ED's treatment areas as rooms become available.
After placement in the PNT area, patients are moved to a private exam room if needed, where the PNT team obtains the history and conducts the physical exam. The patient is then seated in a chair in the PNT hallway. The attending physician orders blood work, IVs, medications, and imaging as needed. The LPN places the IV, draws blood work, and administers any prescribed medications. If there is any medication that the LPN cannot administer due to their scope of practice, the attending physician or a lead RN covering the ED administers it. In the PNT hallway area, patients receive their treatment, diagnosis, reassessment, and disposition. PNT patients can also be discharged or placed on observation while in the hallway. If a PNT patient needs to be admitted and an inpatient room is not immediately available, the patient is moved to the main ED for boarding. If PNT patients are identified to need resources exceeding those of the PNT area, (e.g., those with unstable vital signs), then those patients will be moved to the main ED treatment areas. At the end of the PNT evening shift, any remaining patients are moved to the main ED and signed out to the main ED teams. A comparison between the pre- and post-PNT workflows is presented in Table 1.
Comparison of pre-and post-PNT workflow
Methods of measurement and outcome measures
Individual patient encounter data collected for this study include age, encounter ESI (level 1 to 5), sex, ED disposition, ED arrival time, ED provider contact time, and ED departure time. Aggregate data collected include LWBS, 72-hour revisits, admission rate, and patients per hour.
The ED operations time and process metrics were based on consensus definitions [21]. ED LOS is defined as the duration from a patient’s arrival to their departure. ED arrival-to-provider time is defined as the interval time between a patient’s arrival and their first contact with a provider, while ED LWBS is the proportion of patients leaving before their first contact with a provider. The admission rate is the percentage of patients being admitted to the hospital for further treatment or observation at the conclusion of the ED visit. The 72-hour ED revisits reflects the proportion of patients who returned to the ED within 72 hours of being discharged from the ED.
We analyzed both preintervention ED visits (pre-PNT) and postintervention ED visits (post-PNT), which included patients cared for by the PNT team as well as those who were not. This approach allows for a comprehensive evaluation of the PNT's impact on overall ED operations and throughput.
The primary outcome measure utilized by this study was ED LOS, and secondary outcomes included arrival-to-provider time, LWBS rate, and 72-hour ED revisits.
Statistical analysis
Data were analyzed with IBM SPSS ver. 29 (IBM Corp). Data were summarized and compared with a two-sample t-test for continuous variables and chi-square testing for categorical variables. To account for variations in daily ED volume when analyzing ED LOS, the ED daily census was divided into volumes of low (<205 patients), medium (205 to 222 patients), and high (>222 patients), dividing the cases approximately into thirds. A multivariable linear regression analysis was performed using age, sex, census volume (low, medium, high), ESI, weekend shifts, boarding hours, and day shifts as potential predictor variables of ED LOS.
RESULTS
Characteristics of study subjects
In total, 23,516 patient visits were examined. During the pre-PNT period, 10,228 visits met the inclusion criteria. In the post-PNT period, 13,288 visits met the inclusion criteria, of which 2,454 were PNT visits and 10,834 were non-PNT visits. We report the characteristics of patient visits in Table 2. For the pre- and post-PNT comparison groups, there were no clinically significant differences in age, sex, ESI, and patients per hour.
Characteristics of emergency department visits for pre- and post-PNT groups (n=23,516)
Main results
There was no missing data except for four missing ESI values. Therefore, any statistics or analyses that included ESI excluded these four cases. For all patients (admitted and discharged), the post-PNT visits had a decreased mean LOS compared to the pre-PNT visits from 492±457 to 425±394 minutes (difference, –67 minutes; 95% confidence interval [CI], –78 to –57; P<0.001). For discharged patients, the post-PNT visits had a decreased mean LOS compared to the pre-PNT visits from 401±268 to 353±268 minutes (difference, –48 minutes; 95% CI, –56 to –41; P<0.001). For admitted patients, the post-PNT visits had a decreased mean LOS compared to the pre-PNT visits from 773±726 minutes to 673±602 minutes (difference, –100 minutes; 95% CI, –135 to –65; P<0.001) (Table 3). ED LOS also decreased for post-PNT patients compared to pre-PNT patients regardless of ESI or ED census volume (Table 4).
ED LOS for pre- and post-PNT groups (includes both PNT and non-PNT patients)
Comparisons of ED LOS by ESI and census volume levels
For LWBS, the post-PNT period had a decreased rate compared to the pre-PNT period: from 6.7% to 3.3% (difference, –3.4%; 95% CI, –4.0% to –2.8%; P<0.001) (Fig. 3A). For 72-hour revisits, the post-PNT visits had a decreased revisit rate compared to the pre-PNT visits: from 5.1% to 4.0% (difference, –1.1%; 95% CI, –1.7% to –0.6%; P<0.001) (Fig. 3B). For arrival-to-provider time, the post-PNT visits had a decreased mean time compared to the pre-PNT visits: from 74±88 to 60±65 minutes (difference, –14 minutes; 95% CI, –15.7 to –11.6; P<0.001) (Fig. 3C).
Before and after attending physician–licensed practical nurse (PNT) initiative. (A) Left-without-being-seen (LWBS) rate. (B) The 72-hour revisit rate. (C) Arrival-to-provider time. ***P<0.001.
The multivariable analysis was performed using linear regression with age, sex, census volume (low, medium, high), ESI, weekend shifts, boarding hours, and day shifts as potential predictor variables for ED LOS (Table 5). Fig. 4 shows ED LOS by ESI, census volume, and PNT category (pre-PNT vs. post-PNT). ESI level 1 patients were excluded because there was only one patient in each of the PNT categories. Within every volume group, ED LOS decreased with decreasing severity.
Multivariable regression model for emergency department length of stay
The emergency department (ED) length of stay (LOS) by attending physician–licensed practical nurse (PNT) category, Emergency Severity Index (ESI), and census volume. (A) Low volume (<205 patients). (B) Medium volume (205–222 patients). (C) High volume (>222 patients). *P<0.05.
The patients who were managed by the PNT had a total mean LOS of 237±243 minutes. Discharged PNT patients had a mean LOS of 220±179 minutes and admitted PNT patients had a mean LOS of 307±363. The admission rate for the PNT was 4% (Table 6).
Characteristics of ED visits for PNT patients
DISCUSSION
This study describes an ED workflow change in a high-volume, academic ED with many operational challenges, including limited ED space and RN staffing shortages. The creation of the PNT initiative was implemented without constructing new areas or hiring additional RNs. Attending physicians who were previously assigned to the ED clinical decision unit (which had closed due to nursing staffing shortages) were reassigned to the PNT. This contrasts with other studies, which have shown throughput improvements through constructing new areas [14], creating fast tracks [22,23], creating advanced triage protocols [24,25], and adding providers to triage [26,27]. To alleviate the current RN shortage, our study utilized LPNs to streamline our PNT process, which is a unique model for a front-end ED process.
Key interventions in our study included positioning the PNT adjacent to triage and utilizing mobile computers and procedure carts to optimize workflow. Additionally, patients were examined in a private room, but placed in the hallway for lab and imaging results, reevaluation, and disposition. We also leveraged the scope of practice for LPNs to place IVs, perform blood work, and administer a limited list of medications. The RN leadership was available to help administer any treatments that were outside the LPN scope of practice.
We found that post-PNT patients, compared to pre-PNT patients, exhibited shorter arrival-to-provider times; lower total patients who came through the ED, lower total discharge from the ED, lower admitted LOS, and a reduced percentage of 72-hour revisits. Furthermore, the post-PNT rate of LWBS was lower than the pre-PNT rate. Thus, the novel PNT workflow significantly improved operations and patient outcomes. These findings demonstrate that PNT can successfully improve ED throughput and operational metrics by leveraging the role of LPNs without requiring the construction of additional ED space.
Although major process improvements for the ED had been implemented for over a year before the start of this study, inpatient hospital flow improvements during the study period may have impacted ED boarding. We believe this had minimal influence on the PNT due to the lack of boarding in the PNT, but it may have positively impacted the main ED zones (non-PNT).
Future initiatives should validate the findings from this study in other ED settings to test generalizability and reduce possible confounders or bias by randomization.
The findings presented in this study come with limitations. This study took place in a single-site, large, suburban, academic ED, which may limit generalizability to other settings. The study was a before-and-after design which may not account for temporal factors not part of the intervention design that took place between the before and after study periods. PNT patients were selected directly from the waiting room by the PNT team. The PNT team chose patients who were likely to be discharged after the ED workup, could be cared for in a hallway, and did not need cardiac monitoring, which could result in selection bias. The Hawthorne effect presents another possible limitation since ED staff were aware of the enacted changes. Additionally, the LPN scope of practice may vary by state and institution, further limiting the applicability of our study to dissimilar settings.
In conclusion, this study presents evidence supporting the efficacy of the PNT model in addressing front-end bottlenecks in the ED. Our findings indicate that LPNs can effectively assist in the front-end process, particularly in response to the current RN shortage. The implementation of the PNT resulted in improved ED throughput, reduced revisit rates, and decreased LWBS rates. Importantly, these improvements were achieved without the need for constructing new beds or rooms. These results highlight the potential of the PNT model as an effective strategy to enhance ED operations and improve patient outcomes.
Notes
Author contributions
Conceptualization: all authors; Data curation: SMH, HT; Formal analysis: SMH, HT; Investigation: SMH, AJS; Methodology: SMH, HT, AJS; Project administration: SMH, RS, PV, CK, AR, AJS; Resources: SMH, AJS; Supervision: PV, AJS; Validation: SMH, RS, HT, AJS; Visualization: SMH, RS, HT; Writing–original draft: SMH, RS; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Conflicts of interest
Adam J. Singer is the editor-in-chief of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.
Funding
The authors received no financial support for this study.
Data availability
Data analyzed in this study are available from the corresponding author upon reasonable request.
Additional information
This study was presented at the Society for Academic Emergency Medicine (SAEM) Annual Meeting on May 17, 2023, in Austin, TX, USA.
References
Article information Continued
Notes
Capsule Summary
What is already known
To reduce crowding and improve efficiency, emergency departments (EDs) have tried strategies like redesigning the front-end, involving providers in triage, direct bedding, bedside registration, split flow, and bed expansion. While no single initiative is universally effective, success depends on factors like ED setup, staffing, and patient demographics. Given the constraints of limited space and registered nurse (RN) staffing, there is a pressing need for a process that optimizes existing space and resources without adding beds or requiring more RNs.
What is new in the study
This study investigated the effectiveness of an innovative attending physician–licensed practical nurse team (PNT) located near triage to manage patients without assigned rooms in the ED. Our goal was to alleviate front-end bottlenecks and enhance throughput without the need for new construction or changes to triage protocols at a large, suburban, academic ED. The PNT model led to significant improvements in flow, throughput, revisit rates, and rates of patients who left without being seen.