Strategies to measure and improve emergency department performance: a scoping review

Designed to allow for rapid medical intervention and care escalation, senior doctor triage/ team triage involves the presence of a (senior) emergency doctor (physician) in triage to identify potential emergencies, initiate diagnostics and treatment prior to patients being seen in ED [8, 15‐22].

Dedicated triage resources include a dedicated ECG technician and machine, and the creation of a dedicated ECG room with two stretchers beside triage [23]

Staff education about atypical presentations, signs and symptoms, as well as how to perform ECGs have been implemented [23]

Variations in triage systems include prioritising patients without providing treatment, prioritising patients while providing simple treatment and formal triage systems [15]

Triage protocols procedures for specific symptoms and treatments, for example, nurse-requested radiograph protocol outlines the rules and procedures under which nurses can/ should request radiographs for patients at triage [24]

Nurse-led-triage involves triage by a Nurse Practitioner, Advanced Nurse Practitioner, Emergency nurse Practitioner, or ED nurse [26]

Handover tools standardise communication using a structured information template performed either verbally or nonverbally [28]. For example, Identification, Situation, Background, Assessment, Requirements and Requests (ISBAR) is a tool for face-to-face beside handover [27‐30]. Other tools include Situation, Background, Assessment, Responsibilities and Risks, Discussion and Disposition, Read-back and Record (SBAR-DR) model for verbal handoff, Mechanism of Injury/Illness, Injuries, Signs, observations and monitoring, and Treatment given (MIST; DeMIST includes Demographic information to the handover), hospital developed handover tools, as well as written handover, handover added to patients paper chart, and an eSignout step added to the ED dashboard [27‐30].

Bedside registration immediately following tirage involves, when beds are available, patients are brought immediately through to the patient care area following triage where they are registered by a clerk whilst simultaneously being assessed by medical staff [19, 31].

At a clinical level, discharge planning involves the early planning of patients’ care after discharge [31]

Discharge communication should include important information about the illness, verification of comprehension, and tailoring discharge instructions to address areas of misunderstanding [32]. Interventions to improve discharge communication include education or the sharing of information with patients and the different modes through which information is delivered (e.g., video, interactive websites, written, face-to-face), overcoming existing barriers, or providing additional support to encourage a specific behaviour [32].

Closely linked with handover tools, process protocols and guidelines outline procedures and rules clarifying the transfer of responsibility, as well as a structure for handover [27, 29, 30]. Handover training lasting 3 h, covered five rules of communication, case scenario simulation and a handover protocol [29]

A new clinical role in the form of a dedicated offload nurse for triaging and assessing EMS patients [30]. Another role developed to facilitate handover is the nurse discharge coordinator [33]. The nurse discharge coordinator intervention involves the role discussing with the patient, their health care needs, education, referral to outpatient facility, 24 h nurse follow-up, back-up consultation 1 week after discharge [33]

Process redesign also refers to changes to existing or the introduction of evidence-based clinical practice guidelines for specific conditions [31], protocols (pathology: [31]; treatment: [25]; medication: [34, 42], mandating the redundant reading of emergency CT scans [35].

Patient assignment processes [31], and referral processes [4, 31, 36]. Case management involves the identification of appropriate providers and services for individual patients based on a continuous, integrated medical and psychosocial model of care [37, 38].

Communication and consultation intervention between radiologists and ED physicians to reduce patient call backs to the ED [35], administrative interventions (e.g., outsourcing environmental services, [25]), the addition of administrative, clinical and ancillary personnel [39], logistical changes in radiology and laboratory [39], rearranging bed zones [39], performance targets (e.g., the 4 h rule, disposition [19, 40];.

Nurse-initiated care processes consist of various interventions relating to nursing activities [8]. Reviews examined interventions relating to nurse-initiated care processes in ED including medication [41, 42], x-ray [8, 17, 21, 43, 44], protocols [19], and diagnostic tests [44].

Clinical decision supports refers to the use of a validated clinical decision rule to assess the pre-test probability of the diagnosis [45, 46] or tool to assess the need for diagnostic investigations [47]. For example, tools to assess the need for imaging in adult patients include the National X-radiography Utilization Study (NEXUS) criteria, and the Canadian C-Spine Rule (CCR [47];).

Lean management/ thinking is a suite of concepts, methods and tools developed by Toyota Motor Corporation [48‐50]. Lean processes are designed to improve productive capacity and reduce waste [48‐50]. Three reviews examined Lean interventions in ED [48‐50]. Lean has been applied in a number of ways. For example, designing a detailed map of the process (Value Stream Map – VSM) to identify waste and bottlenecks [48], streaming patients according to severity, dedicating different ED spaces for different types of patients [48] with dedicated nurse and physician for the different areas [48]. Other lean interventions included computer systems implantation, changes in roles and responsibilities, flow managers and screening nurses [48]. Kaizen events moderated by lean consultants or lean specialist (VSM, leadership involvement, boot camp, reallocation of staff, commitment of the department chairperson, communication board, periodic electronic communication [48];). Process changes such as new processes and related operating procedures including eliminating outdated policies, fast-track process for low complexity patients. System changes include data collection and monitoring (e.g., weekly review, quality improvement measurements taken and shared with staff), education/ training (orientation to the new process, posting process map in public areas), tools/ technology (standardised forms, checklists), communication and teamwork (communication tools, team assessment of patient history), staffing reassignment/ new roles/ responsibilities (reassignment to match peak patient volume or arrival rates, dedicated ECG and laboratory technician in ED, reassignment/ reorganisation of space (e.g., space reallocated for rapid assessment and holding patients, designated physician examination rooms), other changes (stocking done as needed, improved signage, celebrating goal achievements) [49]. Lean intervention team composition included, hospital management team or the head of ED, physicians, nurses, staffs and external counsellors, as well as external consultants (experts in lean [50];.

For example, Chest Pain Observation Units are for patients presenting with chest pain who are a low risk of acute myocardial infarction to undergo a short period of monitoring with serial ECGs and cardiac enzymes before further testing and discharge [53].

Rapid Assessment Zones/ Pods (also referred to as Minor Injury Units) are spaces in ED adapted for clinician assessment and procedures for patients whose therapeutic needs exceed typical fast-track criteria, but can still receive investigations/ therapy in a chair and require limited observation [18, 55]. In Rapid Assessment zones/ pods, investigations are initiated, patients wait for results and/ or receive treatment in a chair or stretcher [55].

Medical Assessment Units are areas in ED for patients with complex medical conditions who will likely require admission [4, 8, 17]. Medical Assessment Units involve fast-tracking care of medically stable patients [17].

Short Stay Units are spaces in ED for patients who require a short period of observation, treatment (e.g., blood transfusions), or further diagnostic investigations that may take several hours to resolve without occupying ED beds or being admitted [8, 17, 54, 56].

ED managed acute care unit is a space physically remote from ED but staffed by ED for ED patients who require observation or management for more than 4 h [19].

Quick Diagnostic Units have been introduced to ED to manage referrals from GPs to EDs and are staffed by internal medicine specialists [18]. ED-based observations similar to the Quick Diagnostic Unit include Clinical Decision Units, Medical Assessment and Planning Units, Rapid Assessment and Planning Units, Observation bays, Express Admission Units [18].

Computerised physician order entry [45] and computerised provider entry forms provide clinicians with timely electronic access to patient information and electronic decision support (e.g., alerts, reminders, order sets [58];).

Different types of mobile devices/ workstations have been employed in ED including hand held personal digital assistant, wireless computers/ mobile work stations, iPod® device [57].

Telecommunication technology (e.g., transmission of video, images, radiological studies, physiological data, and pathology results) to provide care to a patient typically distal from the provider [59].

Computer simulation and modelling interventions use simplified representations of reality to analyse ED patient flow and resource capacity planning [60].

Electronic health records use health information technology to allow virtual health information management and exchange [62]. Two reviews examined eHealth records access in ED [61, 62]. Shared electronic health records (e.g., summary of care records, virtual health record) involved making patient care records (e.g., GP records) available to providers of emergency care [61]. Health information exchange programs can include the sharing of laboratory and imaging tests associated with episodes of care [62].

Scribes are non-licensed health care team members that follow ED doctors during patient care to concurrently document patient history, physical examination, and procedures in an accurate manner as it is being done by the ED doctor [74, 76]. Scribes keep track of laboratory findings and radiological studies, prompt doctors to review test results, assist with referrals, and record other pertinent information [74, 76].

Physician Assistants are fully licensed medical practitioners who are trained to provide care under the direction and supervision of a doctor [75]. While the doctor is ultimately responsible for the patient and established the degree of supervision, physician assistants have autonomy in medical decision making [75]. Typical duties include history taking, physical examination, evaluating laboratory data, instituting treatment, performing procedures screening ED patients with routine problems, admitting certain patients and communicating with consultant services [75].

Liaison mental health services have been located in general hospitals outside of ED, but also located inside EDs [79]. Liaison team composition varies and can include nurses, social workers, psychologists, and psychiatrists [79]. Liaison mental health services see clients directly (most referrals involve 60 min of contact with clients) in both initial and follow-up face to face contact with clients [79]. Liaison mental health services also perform administrative, supervision, audit and research, teaching, and meetings [79]. Some models of liaison mental health services include the integration of extra specialist mental health staff (mental health nurses rather than upskilled ED trained staff) as part of the full time ED team and involved in patient triage, mental health patient assessment, management, referral and liaison with other services [80].

co-located psychiatry liaison personnel or spaces for patients [80] are not integrated into the normal ED team, but could be called upon to see mental health patients in the ED or in a bespoke space [80].

Psychiatry specialist services review and care for ED mental health patients [80]. These teams include social workers, psychiatrist and psychologists who come to the ED after referral from the ED staff [80]. Daily rounds by a psychiatrist in the ED has also been implemented [80].