Impact of Emergency Department Tele-intake on Left Without Being Seen and Throughput Metrics.

Impact of Emergency Department Tele-intake on Left Without Being Seen and Throughput Metrics.

Acad Emerg Med. 2019 Nov 15;:

Authors: Joshi AU, Randolph FT, Chang AM, Slovis BH, Rising KL, Sabonjian M, Sites FD, Hollander JE

Abstract
OBJECTIVE: More than 2 million patients present to a US emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures.
METHODS: We conducted a before and after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11am - 6pm, 7 days per week. Tele-intake providers performed a triage history and physical examination, documented findings and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum (NQF) framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT) and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1- April 1, 2017 versus 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program.
RESULTS: Total ED volume was similar in the before and after periods (19,892 vs 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% CI 2.0-2.5%) to 1.69%; (1.51-1.87%); p<0.001. Overall door to provider time decreased (median 19 [IQR,9-38] v 16.2 [7.8-34.3] minutes; p<0.001); but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (184 minutes [IQR, 100-292] v 184.3 [IQR, 104.4-300]; p<0.001). There was an increase in door to discharge times (146 [IQR, 83-231] v 148 [IQR, 88.2-233.6]; p<0.001) and door to admit times (330 [IQR,253-432] v 357.6 [260.3-514.5]; p<0.001). We saw an increase in LWTC [0.59% (95% CI 0.49-0.70 v 1.1% (CI 0.9-1.2); p<0.001], but no change in AMA [1.4% (95% CI 1.2 - 1.6) v 1.6% (95% CI 1.4-1.78), p=0.21] or LWOT [4.3% (95% CI 4.1-4.6) v 4.4% (95% CI 4.1-4.7), p=0.7. Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%) and gave the patient a better experience (19/22, 86%).
CONCLUSION: Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased left without treatment complete rates and had no impact on LWOT.

PMID: 31733003 [PubMed - as supplied by publisher]