Does Practice Match Protocol? Outcomes of More-Acute Emergency Department Patients Seen After Less-Acute Patients Arriving Nearly-Simultaneously
Authors: Tsige Temesgen T , Nasir Rida , Puca Daisy , Charles Kevin , LoGalbo Sandhya , Iyeke Lisa , Jordan Lindsay , Sierra Melva Morales , Silver David , Richman Mark 
Published: October 2024

Introduction Emergency Departments (EDs) serve as the first line of healthcare, addressing a range of conditions from minor to life-threatening. With rising patient volumes, many EDs have adopted innovative models like the split-flow system to increase efficiency and manage overcrowding. The split-flow model, designed to improve efficiency, directs lower-acuity patients to a Fast Track area while higher-acuity cases remain in the main ED. However, this model can lead to lower-acuity patients being seen by a provider before more-acute patients, raising concerns about delayed care for more-acute patients. This study aims to investigate whether prioritizing less-acute patients impacts disposition outcomes for more-acute patients, focusing on admission rates and 30- and 90-day return visits. We hypothesized that more-acute patients seen after near-simultaneously arriving less-acute patients will experience higher rates of return visits and increased hospital readmissions compared to those seen prior to near-simultaneously arriving less-acute patients . Materials and Methods This retrospective observational study assessed the impact of triage practices in the Emergency Department (ED) at Long Island Jewish Medical Center (LIJ), a 583-bed tertiary-care hospital. Adult patients (≥ 18 years) presenting to the ED between April 24 and December 13, 2023, were included, with a sample of 126 patient pairs triaged within 10 minutes of each other. Patients were categorized as high-acuity (ESI 1-2) or low-acuity (ESI 3-5). Data was drawn from electronic health records, including the Emergency Severity Index (ESI) level, the ED location to which the patient was triaged (either Fast Track vs. acute care area), return visits at 30 and 90 days, and patient disposition during the 30-day revisit. Results The study comprised 126 patient pairs (252 patients in total). Overall, there were no statistically-significant differences in outcomes for more-acute patients based on the order in which they were seen. However, when more-acute patients were seen first by a physician, the results indicated that 10% returned to the ED within 30 days, with 63% requiring hospital admission. Additionally, 20% of these patients returned within 90 days. Conversely, when less-acute patients were prioritized, 22% of more-acute patients returned to the ED within 30 days, with only 45% requiring admission, and the 90-day return rate increased to 26%. Conclusion Research has demonstrated a connection between timely care and improved patient outcomes. Our previous study revealed that less-acute patients were seen prior to near-simultaneously-arriving more-acute patients approximately 40% of the time. This raises significant ethical concerns, as it contradicts the fundamental principle of emergency medicine, which emphasizes treating patients based on acuity. Although this current study found no significant differences in dispositional outcomes based on the order in which more-acute patients were seen, the trends suggest that seeing more-acute patients later might lead to worse outcomes. When more-acute patients were seen first, 10% returned to the ED within 30 days, with 63% requiring hospital admission, and 20% of indexed patients returned within 90 days. However, when less-acute patients were seen first, the 30-day return rate for more-acute patients increased to 22%, with 45% needing hospital admission, and the 90-day return rate rose to 26%. EDs must develop strategies to balance operational efficiency with the need to prioritize higher-acuity patients to ensure that operational practices do not compromise patient safety.