title: The role of triage nurse ordering on mitigating overcrowding in emergency departments: a systematic review.
abstract: OBJECTIVE
  The objective was to examine the effectiveness of triage nurse ordering (TNO) on mitigating the effect of emergency department (ED) overcrowding.
  
  
  METHODS
  Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, HealthSTAR, Dissertation Abstracts, ABI/INFORM Global), controlled trial registry websites, conference proceedings, study references, experts in the field, and correspondence with authors were used to identify potentially relevant studies. Interventional studies in which TNO was used to influence ED overcrowding metrics (length of stay [LOS] and physician initial assessment [PIA]) were included in the review. Two reviewers independently assessed study eligibility and methodologic quality. Mean differences were calculated and reported with corresponding 95% confidence intervals (CIs).
  
  
  RESULTS
  From more than 14,000 potentially relevant studies, 14 were included in the systematic review. Most were single-center ED studies; the overall quality was rated as weak, due to methodologic deficiencies and variable outcome reporting. TNO was associated with a 37-minute mean reduction (95% CI = -44.10 to -30.30 minutes) in the overall ED LOS in one randomized clinical trial (RCT); a 51-minute mean reduction (95% CI = -56.3 to -45.5 minutes) was observed in non-RCTs. When applied to injured subjects with suspected fractures, TNO interventions reduced ED LOS by 20 minutes (95% CI = -37.5 to -1.9 minutes) in three RCTs and by 18 minutes (95% CI = -23.2 to -13.2) in two non-RCTs. No significant reduction in PIA was observed in two RCTs.
  
  
  CONCLUSIONS
  Overall, TNO appears to be an effective intervention to reduce ED LOS, especially in injury and/or suspected fracture cases. The available evidence is limited by small numbers of studies, weak methodologic quality, and incomplete reporting. Future studies should focus on a better description of the contextual factors surrounding these interventions and exploring the impact of TNO on other indicators of productivity and satisfaction with health care delivery.
authors.affiliation: Department of Emergency Medicine, School of Public Health, University of Alberta, Edmonton, Canada. brian.rowe@ualberta.ca
authors.forename: Brian H
authors.initials: BH
authors.lastname: Rowe
authors.forename: Cristina
authors.initials: C
authors.lastname: Villa-Roel
authors.forename: Xiaoyan
authors.initials: X
authors.lastname: Guo
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Bullard
authors.forename: Maria
authors.initials: M
authors.lastname: Ospina
authors.forename: Benjamin
authors.initials: B
authors.lastname: Vandermeer
authors.forename: Grant
authors.initials: G
authors.lastname: Innes
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Schull
authors.forename: Brian R
authors.initials: BR
authors.lastname: Holroyd
mesh_terms: D003441:Crowding; D016529:Emergency Nursing / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D024802:Nurse's Role; D009730:Nursing Assessment; D011786:Quality Control; D014218:Triage