Art:10.1186/s12873 016 0102 5 PDF
Art:10.1186/s12873 016 0102 5 PDF
Art:10.1186/s12873 016 0102 5 PDF
Abstract
Background: Emergency department (ED) overcrowding is frequently described in terms of input- throughput and
output. In order to reduce ED input, a concept called primary triage has been introduced in several Swedish EDs. In
short, primary triage means that a nurse separately evaluates patients who present in the Emergency Department
(ED) and either refers them to primary care or discharges them home, if their complaints are perceived as being of
low acuity. The aim of the present study is to elucidate whether high levels of in-hospital bed occupancy are
associated with decreased permeability in primary triage. The appropriateness of discharges from primary triage is
assessed by 72-h revisits to the ED.
Methods: The study is a retrospective cohort study on administrative data from the ED at a 420-bed hospital
in southern Sweden from 2011–2012. In addition to crude comparisons of proportions experiencing each
outcome across strata of in-hospital bed occupancy, multivariate models are constructed in order to adjust for
age, sex and other factors.
Results: A total of 37,129 visits to primary triage were included in the study. 53.4 % of these were admitted to the ED.
Among the cases referred to another level of care, 8.8 % made an unplanned revisit to the ED within 72 h. The
permeability of primary triage was not decreased at higher levels of in-hospital bed occupancy. Rather, the permeability
was slightly higher at occupancy of 100–105 % compared to <95 % (OR 1.09 95 % CI 1.02–1.16). No significant association
between in-hospital bed occupancy and the probability of 72-h revisits was observed.
Conclusions: The absence of a decreased permeability of primary triage at times of high in-hospital bed occupancy is
reassuring, as the opposite would have implied that patients might be denied entry not only to the hospital, but also to
the ED, when in-hospital beds are scarce.
Keywords: Emergency medicine, Bed occupancy, Emergency Department revisits, Triage
Background the most influential [1, 5]. Our group recently showed that
Emergency Department (ED) overcrowding has received scarcity of in-hospital beds (i.e., hospital crowding) not
considerable attention in the literature [1–3]. ED over- only increases ED length of stay (EDLOS) [6], but also
crowding is defined as a situation where the need for causes more patients to be discharged from the ED rather
emergency services exceeds available resources, and its than being admitted to the hospital [7, 8].
causes have been divided into input, throughput and out- Several strategies aimed at reducing ED overcrowding
put factors [4], of which the last have been suggested to be through managing ED input- and throughput factors have
been proposed [9]. These include fast-track service lines [9,
* Correspondence: [email protected]
10], adding a physician to triage [10–13], test ordering by
1
IKVL/Avd för medicin, Universitetssjukhuset, Hs 32, EA-blocket, plan 2, 221 nurses [9, 10, 14, 15] and introducing primary care profes-
85 Lund, Sweden sionals in hospital EDs [16]. Other strategies aim at
Full list of author information is available at the end of the article
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Blom et al. BMC Emergency Medicine (2016) 16:39 Page 2 of 8
Results hoc power analysis indicated that the study did not have
160,462 visits were registered in Patientliggaren® 2011– sufficient power to establish the difference between occu-
2012. 37,129 visits were evaluated in primary triage and pancy 95–100 % and the reference category. Using the oc-
19,829 (53.4 %) of these were admitted to the ED. Of the cupancy as measured 3 h prior to patient presentation
17,300 cases discharged from primary triage, 1,529 yielded the following proportions: 52.6 % admitted to the
(8.8 %) made an unplanned revisit to the ED within ED at occupancy <95 %, 53.7 % at 95–100 %, 54.8 % at
72 h. 100–105 % and 55.9 % at >105 % (p = 0.003). Post hoc
power analysis indicated that the study did not have suffi-
Crude analysis cient power to establish the difference between either oc-
The proportion of visits to primary triage resulting in cupancy 95–100 % or >105 % and the reference category.
admission to the ED was 52.3 % at in-hospital bed- Among the 17,300 cases who were discharged from
occupancy <95 %, 53.5 % at 95–100 %, 56.0 % at 100– primary triage, the proportion of unplanned revisits to
105 % and 57.3 % at occupancy >105 % (p < 0.001). Post the ED within 72 h was 8.8 % at occupancy <95 %, 9.0 %
Fig. 1 Adjusted analysis. Odds-ratio for ED admission, compared to occupancy <95 % (measured at presentation)
Blom et al. BMC Emergency Medicine (2016) 16:39 Page 5 of 8
Fig. 2 Adjusted analysis. Odds-ratio for ED admission, compared to occupancy <95 % (3 h timelag)
at 95–100 % and 8.7 % at >100 % (p = 0.885). Using the variable is shown in Figs. 1 and 2. The only significant dif-
occupancy as measured 3 h prior to patient presentation ference in ED admission was found at occupancy 100–
yielded proportions of 9.4 % at occupancy <95 %, 8.2 % 105 % compared to <95 % (OR 1.09 95 % CI 1.02–1.16).
at 95–100 % and 8.2 % at >100 % (p = 0.020). Post hoc This effect did not remain in the sensitivity analysis. After
power calculations indicated that the study did not have stratifying for high ED inflow, the effect was visible in both
sufficient power to establish these differences. Basic de- the main analysis and the sensitivity analysis for shifts not
scriptive statistics across each of the outcomes are experiencing high ED inflow, with 95 % CI for OR 1.06–
shown in Table 2. 1.24 and 1.01–1.18 respectively. The p-values from the
Wald test were not statistically significant after applying
the Bonferroni correction.
Adjusted analysis Neither model addressing ED admission displayed any
All independent variables screened for inclusion in the large standardised residuals. No significant differences in
multivariate models were included in the preliminary 72-h revisits were revealed in any of the models (see
primary effects models. The interaction term of in- Figs. 3 and 4). The models addressing 72-h revisits dis-
hospital bed occupancy*high ED inflow was significantly played some disturbing residual statistics, which is why
associated with the outcome in both models addressing they are considered less reliable than those addressing
the proportion admitted to the ED. This warranted ED admission. A detailed account of the multivariate
stratification by high ED inflow, in addition to the ana- models is given in Additional files 2 and 3.
lysis with the interaction term omitted.
Neither of the analyses indicated problems with multi- Discussion
collinearity or multivariate outliers. The odds-ratio (OR) Study results do not suggest that the permeability of pri-
for ED admission for different levels of the exposure mary triage decreases at higher levels of in-hospital bed
Fig. 3 Adjusted analysis. Odds-ratio for 72-h revisit, compared to occupancy <95 % (measured at presentation)
Blom et al. BMC Emergency Medicine (2016) 16:39 Page 6 of 8
Fig. 4 Adjusted analysis. Odds-ratio for 72-h revisit, compared to occupancy <95 % (3 h timelag)
occupancy. This holds true for occupancy measured at pa- the results is impaired because of the fact that the study
tient presentation as well as 3 h prior. The differences re- was conducted at a single ED. This is especially true if com-
vealed in the crude analysis rather pointed towards an paring to systems where legislation (e.g., U.S. EMTALA)
increased permeability of primary triage at occupancy prohibits diversion from the ED without proper medical
>105 % and at 100–105 % compared to at <95 %. Even screening. Even though strategies to reduce ED input by di-
though these differences were smaller than what was con- verting patients to other levels of care are becoming less
sidered clinically meaningful prior to conducting the study, popular internationally [29], they are not uncommon in
the post hoc power analysis revealed adequate statistical Sweden. Even though some patients presenting in the ED
power and the findings deserve some elaboration. It is pos- may do so inappropriately, the authors believe that using
sible that the results reflect a situation occurring when primary triage nurses to divert patients away from the ED
nurses in primary triage are asked to assist ED staff at times may be risky, since a thorough evaluation is often required
of high workload. The proposed causal chain is then that, to rule out serious underlying disease. More thoroughly
when their workload is high, nurses in primary triage dis- researched strategies to deal with less urgent patients in the
play a tendency to admit patients to the ED when in doubt, ED include introducing primary care professionals [16] and
rather than to invest additional time in undertaking a more fast-track services [9, 10] to the ED. Furthermore, several
thorough evaluation. This would imply that the intended strategies for improving ED throughput [1, 9] and output
effect of primary triage diminishes when it is needed the [30–34] are available.
most (i.e., when strain on ED staff is high). The effect of
bypassing primary triage altogether could not be measured Conclusions
in the present study, since only patients assessed in primary The present study does not support the hypothesis that
triage were included. primary triage nurses divert more patients away from
Limitations in study power led to the collapsing of the ED at times of high in-hospital bed occupancy. This
occupancy-strata for the analysis of 72-h revisits, is reassuring, as the opposite would have implied that
which should be able to detect differences in the pro- patients might be denied thorough medical assessment
portions revisiting the ED of 2 % and larger. The lack in the ED at times of hospital crowding. Interestingly,
of a significant association between in-hospital bed oc- the permeability of primary triage appears to increase
cupancy and the proportion of 72-h revisits suggests slightly at times of high demand for ED resources, which
that the appropriateness of discharges from primary is contrary to its purpose.
triage was not severely affected by in-hospital bed oc-
cupancy. This would be in line with the main find-
ings, which suggest that patients are not “bounced” by Additional files
primary triage to a larger extent when in-hospital bed
occupancy is high. Additional file 1: Schematic illustration of primary triage process.
Since registration in Patientliggaren® is mandatory for all (PDF 31 kb)
patients entering the facility, differential losses of data are Additional file 2: Variable characteristics, multivariate models. (PDF 51 kb)
unlikely. This is supported by the absence of system crashes Additional file 3: Variable characteristics, multivariate models, stratified
by shift intensity. (PDF 66 kb)
during the study period. However, the generalizability of
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