Impact of employing primary healthcare professionals in emergency department triage on patient flow outcomes: a systematic review and meta-analysis

Abstract

Objectives: To identify, critically appraise and summarise evidence on the impact of employing primary healthcare professionals (PHCPs: family physicians/general practitioners (GPs), nurse practitioners (NP) and nurses with increased authority) in the emergency department (ED) triage, on patient flow outcomes.

Methods: We searched Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) (inception to January 2020). Our primary outcome was the time to provider initial assessment (PIA). Secondary outcomes included time to triage, proportion of patients leaving without being seen (LWBS), length of stay (ED LOS), proportion of patients leaving against medical advice (LAMA), number of repeat ED visits and patient satisfaction. Two independent reviewers selected studies, extracted data and assessed study quality using the National Institute for Health and Care Excellence quality assessment tool.

Results: From 23 973 records, 40 comparative studies including 10 randomised controlled trials (RCTs) and 13 pre-post studies were included. PHCP interventions were led by NP (n=14), GP (n=3) or nurses with increased authority (n=23) at triage. In all studies, PHCP-led intervention effectiveness was compared with the traditional nurse-led triage model. Median duration of the interventions was 6 months. Study quality was generally low (confounding bias); 7 RCTs were classified as moderate quality. Most studies reported that PHCP-led triage interventions decreased the PIA (13/14), ED LOS (29/30), proportion of patients LWBS (8/10), time to triage (3/3) and repeat ED visits (5/6), and increased the patient satisfaction (8/10). The proportion of patients LAMA did not differ between groups (3/3). Evidence from RCTs (n=8) as well as other study designs showed a significant decrease in ED LOS favouring the PHCP-led interventions.

Conclusions: Overall, PHCP-led triage interventions improved ED patient flow metrics. There was a significant decrease in ED LOS irrespective of the study design, favouring the PHCP-led interventions. Evidence from well-designed high-quality RCTs is required prior to widespread implementation.

Prospero registration number: CRD42020148053.

Keywords: accident & emergency medicine; adult intensive & critical care; intensive & critical care.

Figure 1

PRISMA study flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Various models for PHCP involvement in triage of emergency department patients. ED, emergency department; GP, general practitioner; MD, mean difference; NP, nurse practitioner; PHCP, primary healthcare professional.

Figure 3

Effectiveness of primary healthcare professional (PHCP) interventions on time to provider initial assessment (in minutes) subgrouped by study design. The horizontal black lines represent 95% CIs and the red dots in the middle represents point estimates (mean difference). CBA, controlled before and after; RCT, randomised controlled trial.

Figure 4

Effectiveness of primary healthcare professional (PHCP) interventions on ED Los (in minutes) subgrouped by study design. The horizontal black lines represent 95% CIs and the red dots in the middle represents point estimates (mean difference). ED, emergency department; RCT, randomised controlled trial.