title: The impact of senior doctor assessment at triage on emergency department performance measures: systematic review and meta-analysis of comparative studies.
abstract: OBJECTIVE
  To determine if placing a senior doctor at triage versus standard single nurse in a hospital emergency department (ED) improves ED performance by reviewing evidence from comparative design studies using several quality indicators.
  
  
  METHODS
  Systematic review.
  
  
  METHODS
  Cochrane Library, MEDLINE, EMBASE, CINAHL, Cochrane Effective Practice and Organisation of Care (EPOC), Web of Science, Clinical Trials Registry website. In addition, references from included studies and citation searches were used to identify relevant studies.
  
  
  METHODS
  Databases were searched for comparative studies examining the role of senior doctor triage (SDT), published from 1994 to 2014. Senior doctor was defined as a qualified medical doctor who completed high specialty training in emergency medicine. Articles with a primary aim to investigate the effect of SDT on ED quality indicators such as waiting time (WT), length of stay (LOS), left without being seen (LWBS) and left without treatment complete (LWTC) were included. Articles examining the adverse events and cost associated with SDT were also included. Only studies with a control group, either in a randomised controlled trial (RCT) or in an observational study with historical controls, were included. The systematic literature search was followed by assessment of relevance and risk of bias in each individual study fulfilling the inclusion criteria using the Effective Public Health Practice Project (EPHPP) bias tool. Data extraction was based on a form designed and piloted by the authors for dichotomous and continuous data.
  
  
  RESULTS
  Narrative synthesis and meta-analysis of homogenous data were performed.
  
  
  RESULTS
  Of 4506 articles identified, 25 relevant studies were retrieved; 12 were of the weak pre-post study design, 9 were of moderate quality and 4 were of strong quality. The majority of the studies revealed improvements in ED performance measures favouring SDT. Pooled results from two Canadian RCTs showed a significant reduction in LOS of medium acuity patients (weighted means difference (WMD) -26.26 min, 95% CI -38.50 to -14.01). Another two RCTs revealed a significant reduction in WT (WMD -26.17 min, 95% CI -31.68 to -20.65). LWBS was reduced in two Canadian RCTs (risk ratio (RR)=0.79, 95% CI 0.66 to 0.94). This was echoed by the majority of pre-post study designs. SDT did not change the occurrence of adverse events. No clear benefit of SDT in terms of patient satisfaction or cost effectiveness could be identified.
  
  
  CONCLUSIONS
  This review demonstrates that SDT can be an effective measure to enhance ED performance, although cost versus benefit analysis is needed. The potential high risk of bias in the evidence identified, however, mandates more robust multicentred studies to confirm these findings.
authors.affiliation: School of Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK.
authors.forename: Maysam Ali
authors.initials: MA
authors.lastname: Abdulwahid
authors.affiliation: School of Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Booth
authors.affiliation: School of Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK.
authors.forename: Maxine
authors.initials: M
authors.lastname: Kuczawski
authors.affiliation: School of Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK.
authors.forename: Suzanne M
authors.initials: SM
authors.lastname: Mason
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D016529:Emergency Nursing / Q000592:standards; D004636:Emergency Service, Hospital; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D017060:Patient Satisfaction; D010820:Physicians / Q000592:standards*; D014218:Triage; D000078329:Workforce
keywords: emergency care systems, efficiency; emergency department; triage