Patients Negotiating Their Emergency Room Disposition in Primary Care

Purpose: Recent US data (2017) has the hospitalization rate from the emergency room (ER) at 10.4%, continuing attention on the overuse of the ER for symptoms that could be managed cost-efficiently in primary care. The purpose of this evidence-based practice (EBP) quality improvement project was to strengthen the effectiveness of telephone triage nurses’ use of protocols in advising the ER disposition to primary care patients with emergent symptoms.

Description: A centralized team of 17-20 telephone triage nurses receive an average of 250 daily calls from patients seen at seven family practice and internal medicine offices. Patients call triage nurses, who use a symptom-appropriate, evidence-based pediatric (Schmitt) or adult (Thompson) protocol, embedded in EPIC, to generate a disposition, one of which is advising to go to the ER.

Triage administration responded to an internal leadership question about triage nurses appropriately sending patients to ER, resulting in the identified need for a EBP project to address how nurses use the protocols to generate an ER disposition and how the patients respond to the ER advice. A review of telephone triage research found variable results, for example, appropriateness of a triage decision ranged 44-98% and patients’ response ranged 56-98%.

The project planned to first ascertain how the triage nurses used the protocols to advise ER to patients and how the patients responded (time 1), to give an educational update on protocol use at a monthly staff meeting and then one month later to evaluate the nurses’ performances and patients’ responses (time 2). Five items measured steps in protocol use; these are consistent with instructions from the Schmitt and Thompson references. The hospital’s institutional review board approved this project.

Evaluation/outcome: EPIC queries for patients with an ER disposition were done for a 15-day period in in October 2019 (time 1) and in February 2020 (time 2); from each, a random sample was drawn. Trained nurses conducted charts audits on 114 patients for both times. Patients were predominately English-speaking, female, mean age 55, 51, with private insurance, and were 54%, 52% white, 26%, 31% Hispanic, 10%, 11% black (time 1, time 2).

At time 1, triage nurses scored 74%-91% across the five protocol use items; at time 2, after the educational update, improved to 89%-98%. For time 1, 70% of nurses advised the ER to patients; at time 2 89% did. Provider agreement with the protocol-generated ER disposition was 55% at both times; this reflects a negotiation between patients and providers, through triage nurses, after patients told nurses they did not want to go to ER. This negotiation ended with 59% of patients agreeing with either the protocol-generated ER disposition or with the negotiated provider’s disposition at time 1; 73% at Time 2. At time 1, 49 patients (43%) went to the ER, compared to 53 patients (46%) at Time 2. For time 1, the 28.6% hospitalization rate from ER (14 patients) is higher the hospital’s 2018-2019 rate of 15.2% and the US 2017 rate of 10.4%; time 2 rate was 16.9% (9 patients).