title: Implementing wait-time reductions under Ontario government benchmarks (Pay-for-Results): a Cluster Randomized Trial of the Effect of a Physician-Nurse Supplementary Triage Assistance team (MDRNSTAT) on emergency department patient wait times.
abstract: BACKGROUND
  Internationally, emergency departments are struggling with crowding and its associated morbidity, mortality, and decreased patient and health-care worker satisfaction. The objective was to evaluate the addition of a MDRNSTAT (Physician (MD)-Nurse (RN) Supplementary Team At Triage) on emergency department patient flow and quality of care.
  
  
  METHODS
  Pragmatic cluster randomized trial. From 131 weekday shifts (8:00-14:30) during a 26-week period, we randomized 65 days (3173 visits) to the intervention cluster with a MDRNSTAT presence, and 66 days (3163 visits) to the nurse-only triage control cluster. The primary outcome was emergency department length-of-stay (EDLOS) for patients managed and discharged only by the emergency department. Secondary outcomes included EDLOS for patients initially seen by the emergency department, and subsequently consulted and admitted, patients reaching government-mandated thresholds, time to initial physician assessment, left-without being seen rate, time to investigation, and measurement of harm.
  
  
  RESULTS
  The intervention's median EDLOS for discharged, non-consulted, high acuity patients was 4:05 [95th% CI: 3:58 to 4:15] versus 4:29 [95th% CI: 4:19-4:38] during comparator shifts. The intervention's median EDLOS for discharged, non-consulted, low acuity patients was 1:55 [95th% CI: 1:48 to 2:05] versus 2:08 [95th% CI: 2:02-2:14]. The intervention's median physician initial assessment time was 0:55 [95th% CI: 0:53 to 0:58] versus 1:21 [95th% CI: 1:18 to 1:25]. The intervention's left-without-being-seen rate was 1.5% versus 2.2% for the control (p = 0.06). The MDRNSTAT subgroup analysis resulted in significant decreases in median EDLOS for discharged, non-consulted high (4:01 [95th% CI: 3:43-4:16]) and low acuity patients (1:10 95th% CI: 0:58-1:19]), as well as physician initial assessment time (0:25 [95th% CI: 0:23-0:26]). No patients returned to the emergency department after being discharged by the MDRNSTAT at triage.
  
  
  CONCLUSIONS
  The intervention reduced delays and left-without-being-seen rate without increased return visits or jeopardizing urgent care of severely ill patients.
  
  
  BACKGROUND
  NCT00991471 ClinicalTrials.gov.
authors.affiliation: Emergency Services, Sunnybrook Health Sciences Center, Toronto, Canada. ivy.cheng@sunnybrook.ca.
authors.forename: Ivy
authors.initials: I
authors.lastname: Cheng
authors.forename: Jacques
authors.initials: J
authors.lastname: Lee
authors.forename: Nicole
authors.initials: N
authors.lastname: Mittmann
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Tyberg
authors.forename: Sharon
authors.initials: S
authors.lastname: Ramagnano
authors.forename: Alex
authors.initials: A
authors.lastname: Kiss
authors.forename: Michael
authors.initials: M
authors.lastname: Schull
authors.forename: Fergus
authors.initials: F
authors.lastname: Kerr
authors.forename: Merrick
authors.initials: M
authors.lastname: Zwarenstein
mesh_terms: D019985:Benchmarking; D016000:Cluster Analysis; D017598:Efficiency, Organizational; D004636:Emergency Service, Hospital / Q000592:standards / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009313:National Health Programs; D009864:Ontario; D017063:Outcome Assessment, Health Care; D010343:Patient Admission / Q000706:statistics & numerical data; D010348:Patient Care Team / Q000458:organization & administration*; D010351:Patient Discharge / Q000706:statistics & numerical data; D019555:Physician-Nurse Relations; D057184:Practice Patterns, Nurses' / Q000592:standards / Q000706:statistics & numerical data; D012052:Reimbursement, Incentive; D013997:Time Factors; D014218:Triage; D014850:Waiting Lists