If you’ve needed emergency care in the last few years, you probably encountered this situation: Soon after entering the emergency department, you were asked to go to a triage area in the waiting room where a doctor, nurse practitioner, or physician assistant asked you a few questions and ordered some diagnostic tests while you waited.
That’s a departure from the traditional form of triage, in which a nurse assesses the level of acuity of a patient’s illness or injury. This basic and time-honored system ensures that someone with a gunshot wound gets seen before someone with a sprained ankle.
The new “provider-in-triage” system ostensibly accelerates care. On the surface, ordering tests in the waiting room to get the ball rolling might seem like a good way to save time. A closer look reveals a system that sacrifices medical care for hospital profits.
Approximately 150 million Americans will visit an emergency department this year. Many of them won’t be seen right away by their treatment team, and instead will enter into the new triage system.
The provider-in-triage system turns the doctor-patient encounter on its head. In triage, physicians do not practice the thoughtful form of medicine they learned in medical school. Instead they perform a rapid medical evaluation. During this cursory encounter, often lasting less than two minutes, a patient is asked to convey an abbreviated story of what brought him or her to the hospital, the doctor asks a few questions, and performs a limited examination.
None of this is ideal. Patients’ stories are cut short. Physical exams are encumbered by clothing, hiding findings from the doctor’s sight or touch. And interruptions are common.
In a busy emergency department, a doctor or other provider repeats this process in rapid succession, sometimes completing more than 15 rapid medical evaluations in an hour. Using this quick snapshot as a guide, the provider then orders laboratory tests and x-rays, CT scans, or other imaging studies to be used later by the diagnosis and treatment team. Some are necessary, others are not.
Emergency departments were built to deliver fast high-quality medical care when needed. But in very few cases do seconds matter. Patients do best when doctors sit with them, listen to their complete stories, then perform unencumbered physical exams. Only after this can doctors compile a thoughtful list of possible diagnoses. Many of them can be ruled in or out without any blood work or special imaging.
Working with limited information, the provider in triage often resorts to shotgun testing — over-ordering laboratory tests and imaging studies out of fear of missing the diagnosis. Shotgun testing unnecessarily inflates the cost of health care. I once took care of a middle-age man who came to the emergency department because of chest pain. Thinking heart attack, the provider in triage ordered a chest x-ray, an electrocardiogram, and blood work. Later, when an emergency bed became available and I was able to take a complete history and perform a physical exam, I quickly determined that the patient had shingles, a painful rash, across his chest. I didn’t need a chest x-ray, electrocardiogram, or blood work to make that diagnosis. Nevertheless, he left the hospital that day with a bill for thousands of dollars.
Another problem with shotgun testing is that it can lead doctors to make incorrect diagnoses. While having lab and imaging results ready may seem like a good way to speed up care, it isn’t. Seeing test results before meeting a patient can bias a physician’s thinking and nudge him or her to land on the wrong diagnosis. It also leads to extra tests, radiation exposure, and medical procedures that patients don’t need.
Advocates of the provider-in-triage model argue that reducing patient lengths of stay without increasing mortality or return emergency visits justify the practice. These gains are modest. On average, patients spend 26 fewer minutes in the emergency department, though overall patient satisfaction scores are unchanged. And while it’s true that a handful of patients are diagnosed by this type of triage and promptly discharged, saving them a long wait, this comes at the expense of the other patients.
The provider-in-triage model was created by health care consultants who applied the Toyota model of lean production to health care. Hospital administrators and emergency department directors embrace lean production with the hopes of reducing inefficiencies and improving patient throughput. But while a manufacturing model that favors standardization and reproducibility might be ideal for making quality SUVs, it leads to mediocre medicine. Each patient has a unique story and illness that require thoughtful and individualized care, not production-line uniformity.
Hospitals adopt the provider-in-triage model to increase productivity and profitability. Billboards advertising emergency departments with clocks showing wait times are becoming popular across the country. Some hospitals post their wait times online. These practices are deceptive. They lure patients in with short wait times to see the provider in triage, while the real wait time to receive treatment is often measured in hours.
Hospital executives like putting a provider in triage because it allows hospitals to profit off nearly every patient who steps foot into the emergency department. The practice drives down to almost zero the unbillable “left without being seen” encounters. Now hospitals can charge patients for facility and physician fees at the first point of contact in the waiting room. Under the traditional model, patients don’t incur these charges until they see their treating team. This leaves patients who change their mind after they register on the hook for the charges associated with the blood work and diagnostic imaging they had while waiting.
The system creates a financial boon for hospitals, but one that comes at the expense of patients and the health care system.
To patients, the provider-in-triage model can seem like an improvement to emergency care. Being seen quickly is appealing, while the decline in the quality of health care and the financial costs are hidden. But while patients may not perceive that they’ve entered into a one-size-fits-all system that delivers inferior medical care, there’s a palpable feeling among physicians that they are practicing fast-and-loose medicine.
The disjointed, rapid-fire nature of the provider-in-triage system reduces the care doctors provide to a reflexive, cerebellar form of medicine. Being forced into a system that demands physicians to practice dumbed-down medicine to boost hospital profits contributes to “moral injury.” First described in soldiers returning from war, moral injury is “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”
In the medical arena, it has been adapted to describe the feeling of being unable to provide high-quality care and healing in modern health care. The provider-in-triage system contributes to physicians’ feelings of frustration, exhaustion, and moral abdication that drive some to leave the medical profession.
How do we fix this broken system? It would be a moral failure for physicians to let patients advocate for themselves in this fight. We shouldn’t ask patients in a moment of crisis, when they are seeking medical help, to muster the courage and insight necessary to challenge the system. Yes, patients can ask to skip the provider-in-triage and wait to see their treating doctor, but this problem needs a systematic solution.
Physicians can call upon governing bodies, such as the American College of Emergency Physicians and the American Medical Association, to act. They should adopt policy statements that discourage the provider-in-triage model and assist physicians and patients in pressuring administrators and hospitals to change it.
Hospitals, in turn, must give emergency departments the resources they need to deliver timely and high-quality care. This includes sufficiently staffing emergency departments with doctors, nurses, and supporting personnel so patients do not have to wait long to see their treatment team. It also requires structural change within hospitals. Emergency departments need enough beds to efficiently see patients, and patients admitted to the hospital from the emergency department need to move quickly to their inpatient beds so they don’t block the flow of others into the emergency department. Financial incentives are currently aligned against this kind of reform, and change will not come easily.
But doctors and other health care providers are a resilient bunch. This is a fight worth having for our patients.
Keith Corl, M.D., practices both emergency and critical care medicine and is an assistant professor of medicine in the Division of Pulmonary Critical Care at the Warren Alpert Medical School of Brown University, in Providence, R.I. The views expressed here are those of the author.
No, The views expressed here are those of the author.. and many, many others. Thought I was just hearing those voices in my head again at night. Thank you sincerely from a now retired, once upon a time ED Director, who acquiesced.
While the RME isn’t perfect, it is better than having a nurse interview a patient and then ordering labs/tests from a protocol. Shaving 26″ of the average length of stay is huge in a community hospital where the average LOS is 110-120″, better than a 20% improvement. That goes a long way to improving patient flow and throughput.
The point that is being ignored is that the reason we have such a huge volume in the emergency department is the EMTALA law that says all patients presenting to triage will have a screening exam. After passage of the law it was subsequently determined that this exam must be done by someone at a higher provider level than an RN. The result of which was EVERYBODY who presents to triage must be seen by a higher level provider even if they have a hangnail, want a pregnancy test, have had toe pain for the last 10 years etc. This overreach of this law has essentially turned the emergency department into a walk-in clinic. Until there is push back against the overcompensation of EMTALA we will continue to have these problems in emergency care delivery in this country.
Spot on ! Emtala has replaced personal responsibility and common sense is no longer allowed .
I disagree with a large portion of what you are saying. As an ED doc that has done many triage and begin testing while waiting has been very beneficial for our patients. The most experienced physicians do triage and start ups very well without over or under testing. For the next ED doctor that sees the patient, it is very helpful to have a head start on differentials especially the more critical ones. A quick pregnancy test can help decide if an ultrasound is the next step. Calling a surgeon after a CT shows acute appendicitis in a young male is a great jump start. Sometimes we can get a troop in and EKG in triage and be able to repeat that in four hours and send a low risk patients home.
With the volume of Ed visits increasing this is how ED physicians need to practice.
I agree that throwing out a large net of tests without thought has never been helpful
I also disagree with most of what was said in this article–of course if the doctor-in-triage is careless and unthinking and stuck in intuitive / Type 1 thinking, he/she is likely to overorder/underorder tests and investigations. This is rarely the case however. I also agree with Dr Durkin above that 26 minutes is a huge reduction, and is not the only benefit that is offered by reducing the “door-to-doctor time”–these 26minutes must be multiplied by the 50-100 patients per day, which adds up to the savings of many “patient-hours” per day / ie open beds for other patients. So-called “shot-gun” ordering of tests is not good practice by anyone at any time, whether in triage or elsewhere.
The problem is not in applying LEAN and/or other cueing-theory-based efficiency guidelines to the ED; it’s in attempting to force ED operations into overly-simplistic flow-charts that LEAN usually is used for. The ED is orders of magnitude more complex, inter-connected, inter-related and systems-based than any industrial assembly line, warehouse retailer, airline industry, or surgical / anesthesiology list-manifesto-applicable procedure. We need to better staff, train, equip and prepare our ED to match the complex and growing demand our modern medical system is producing and experiencing.
While making some very good points, I think this opinion piece is a little too broad brush. In our ED, which sees 105K/yr., we implemented a provider in Triage model strictly to improve throughput. Neither money nor Administration had anything to do with it – to the contrary, we had to fight to get limited funding for it. Realizing that the most vulnerable patients in the ED are the ones in the WR, we strive to get everyone in front of a provider as quickly as possible. We’ve found that in some cases, the doc in triage picked up on things the Triage nurses probably would have missed.
Dr Cord’s article is an excellent critique of the RME flaws, but good luck with changing the system. Money and rapid medical access are the predominant driving force of this model. The patients also demand quick service.
If the system cannot be changed, at least leave the ordering up to the doctor unless it is a true emergency.
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