DDHA 8203 Week 6 Tradeoff Discussion Post Example

Week 6 Discussion: Tradeoffs in Process Improvement

Nineteen Minutes to a Provider, Paid For in the Back Hallway: Who Absorbs the Cost When an Emergency Department Moves a Physician to Triage

The change I want to examine produced a real gain, and I will state it first. At a composite 38-bed emergency department I will call Fairhaven Memorial, leadership moved one attending physician from the treatment area to triage from 11:00 to 21:00. Within three months, the median time from arrival to first provider contact fell from 48 minutes to 19, and the share of patients who left before being seen fell from 4.1% to 1.6%. Those are large improvements, and they are consistent with what reviews of front-end redesign describe; Rowe et al. (2011), reviewing triage liaison physician models, found that they were generally associated with fewer patients leaving without being seen, though the studies were mostly before-and-after designs of limited quality.

The cost is that the physician in triage is not seeing patients in the treatment area. Fairhaven did not add a provider; it moved one. The patients who absorbed the loss were specific: patients triaged at a mid-level of acuity and placed in a treatment room, waiting for results and then for someone to reassess them and decide whether they could go home. For that group, the median time from the last result to a disposition decision rose by 26 minutes, and their total length of stay rose by about 20 minutes, even though they reached a provider faster. The gain landed at the front door, and the loss landed in the back hallway among patients who were already in a bed.

The measurement problem makes this worse. Fairhaven reports door-to-provider time to its board every month, and it was the measure the change was designed to move. It does not report result-to-disposition time for patients in treatment rooms at all. Asplin et al. (2003) proposed thinking about crowding as input, throughput and output, and the change at Fairhaven improved input while quietly degrading throughput. A department that reports only one of those will see an improvement whether or not the patient's whole visit improved.

My position is that the trade is worth making during the hours when the waiting room is full and patients are leaving unseen, because a patient who leaves without being seen has received nothing. Wiler et al. (2010) describe front-end interventions as most useful when the bottleneck sits at the front. The answer reverses when the bottleneck is behind the triage desk. If boarded inpatients occupy most treatment rooms, a faster first contact only moves patients from the waiting room into a hallway queue for rooms, and the physician would do more good in the back. Fairhaven should report result-to-disposition time beside door-to-provider time, and should return the physician to the treatment area on any shift when boarding passes a set threshold.

Reply to Ingrid

Ingrid, you argue that the treatment-area delay is temporary, because once orders are started in triage the patients in rooms should need less of the physician's time. That is the strongest argument for the model, and Fairhaven hoped for exactly that. Three months in, the data do not show it. Orders started in triage shortened the time to the first result but not the time from result to decision, because the decision still needs a provider who has examined the patient. I would accept your point if result-to-disposition time began falling in the next quarter. Would you set a deadline for it to start falling before you call the delay permanent?

Reply to Owen

Owen, you suggest that the department should have added an advanced practice provider in triage rather than moving a physician, and that the loss would then disappear. I agree that it would shrink, and that may be the right long-term answer. My hesitation is that adding a provider is a different decision from the one Fairhaven made, and it carries a different cost. A post about tradeoffs should judge the change that was actually made. Your proposal also has its own tradeoff to name: an advanced practice provider in triage would need physician supervision for some patients, which would draw on the same treatment-area physician at the busiest hours.

References

Asplin, B. R., Magid, D. J., Rhodes, K. V., Solberg, L. I., Lurie, N., & Camargo, C. A. (2003). A conceptual model of emergency department crowding. Annals of Emergency Medicine, 42(2), 173-180. https://doi.org/10.1067/mem.2003.302

Rowe, B. H., Guo, X., Villa-Roel, C., Schull, M., Holroyd, B., Bullard, M., Vandermeer, B., Ospina, M., & Innes, G. (2011). The role of triage liaison physicians on mitigating overcrowding in emergency departments: A systematic review. Academic Emergency Medicine, 18(2), 111-120. https://doi.org/10.1111/j.1553-2712.2010.00984.x

Wiler, J. L., Gentle, C., Halfpenny, J. M., Heins, A., Mehrotra, A., Mikhail, M. G., & Fite, D. (2010). Optimizing emergency department front-end operations. Annals of Emergency Medicine, 55(2), 142-160. https://doi.org/10.1016/j.annemergmed.2009.05.021