NUR 598 Week 3 Literature Search and Solution

Student Name

University of Phoenix

NUR 598 Research Utilization Project (capstone-style project)

Prof. Name

Date

Literature Search and Solution

Emergency department (ED) crowding is a persistent healthcare challenge that increases patient wait times, length of stay, mortality risk, and the number of patients who leave without being seen. Research suggests that while patient volume cannot always be controlled, improving patient throughput is one of the most effective strategies for reducing overcrowding. Evidence indicates that replacing the traditional nurse-led triage model with a Nurse Practitioner–Registered Nurse (NP–RN) triage team can accelerate patient assessment, initiate treatment earlier, improve patient flow, and enhance overall patient satisfaction.

Emergency Department Crowding and the Need for Better Triage

Emergency department overcrowding continues to place significant pressure on healthcare systems worldwide. Increasing patient demand, limited inpatient capacity, and complex patient needs contribute to prolonged wait times and reduced quality of care. Since emergency departments have little control over the number of incoming patients, healthcare organizations must focus on improving operational efficiency.

One of the most effective approaches is optimizing patient throughput. Faster assessment, earlier treatment, and streamlined triage processes help reduce emergency department congestion while improving clinical outcomes.

Evidence-Based Literature Search

The proposed solution is grounded in evidence-based practice (EBP). Following the Iowa Model of Evidence-Based Practice, the first step involves conducting a comprehensive literature review to identify high-quality evidence that supports clinical decision-making.

Research examining alternative triage models consistently evaluates their impact on:

Emergency department length of stay
Time to provider assessment
Patient wait times
Left Without Being Seen (LWBS) rates
Patient satisfaction
Overall patient flow

Although the quality of evidence varies, systematic reviews, randomized controlled trials (RCTs), and quality improvement studies generally support incorporating advanced practice providers into the triage process.

Critical Appraisal of the Literature

The available literature demonstrates promising results but also highlights several methodological limitations.

Strengths of Existing Research

Several randomized controlled trials and systematic reviews reported significant improvements after introducing providers into triage. Common benefits included:

Reduced patient length of stay
Faster provider evaluation
Earlier initiation of diagnostic testing
Lower rates of patients leaving without treatment
Improved emergency department efficiency

These findings were consistently supported across multiple studies despite differences in healthcare settings.

Limitations of Current Evidence

Despite encouraging outcomes, several challenges reduce the overall strength of the evidence.

Limited High-Quality Studies

Large randomized controlled trials are difficult to conduct because emergency department workflows are dynamic and difficult to standardize.

Inconsistent Data Collection

Many studies relied on manually recorded timing data rather than electronic health records, increasing the possibility of measurement errors.

Confounding Variables

Emergency departments are influenced by numerous factors, including patient acuity, staffing levels, hospital occupancy, seasonal demand, and workflow changes. These variables make it difficult to isolate the effect of a single intervention.

Although these limitations exist, the collective evidence consistently suggests that provider-based triage improves emergency department throughput.

Proposed Solution: Implementing an NP–RN Triage Model

Based on current evidence, replacing the traditional nurse-only triage process with a Nurse Practitioner–Registered Nurse (NP–RN) team offers a practical and cost-effective solution.

Under this model:

Patients classified as Emergency Severity Index (ESI) levels 1 or 2 proceed directly to the treatment area.
The Nurse Practitioner immediately evaluates patients with ESI level 3 and initiates diagnostic testing and treatment before an emergency department bed becomes available.
Many lower-acuity patients (ESI levels 4 and 5) can be treated and discharged directly from triage without occupying treatment beds.

This approach allows medical care to begin earlier, reducing delays throughout the emergency department.

Feasibility of the NP–RN Triage Model

Implementing an NP–RN triage model is operationally feasible in emergency departments that already employ Nurse Practitioners.

Several factors support implementation:

Existing triage areas often provide sufficient space for two clinicians.
Nurse Practitioners working in Fast Track units already possess emergency medicine experience.
Reassigning an existing NP to triage minimizes additional staffing costs.
Current nursing resources can effectively support collaborative triage workflows.

Because the intervention primarily reorganizes existing personnel rather than adding new staff, implementation can be achieved with minimal financial investment.

How the NP–RN Model Improves Emergency Department Throughput

The primary advantage of an NP–RN team is its ability to eliminate unnecessary delays and duplicate tasks.

For example, a patient presenting with symptoms of an uncomplicated urinary tract infection can be assessed, diagnosed, treated, and discharged directly from triage by the Nurse Practitioner. This prevents unnecessary bed utilization and reduces repeated assessments later in the patient journey.

Compared with traditional workflows, this collaborative model:

Starts treatment sooner
Reduces redundant clinical assessments
Improves patient movement through the department
Frees emergency department beds for higher-acuity patients
Enhances resource utilization

Overall, the NP–RN model creates a more efficient front-end emergency department process.

Project Goals

The primary goal is to improve emergency department patient flow while reducing overcrowding and enhancing patient safety.

Improved throughput is expected to produce faster care, shorter wait times, and a better patient experience.

Project Objectives

Successful implementation includes the following objectives:

Establish a multidisciplinary implementation team.
Develop policies and procedures for the NP–RN triage model.
Train emergency department staff, physicians, and Nurse Practitioners.
Modify the triage area to accommodate collaborative practice.
Pilot the NP–RN triage system using alternating implementation days over a three-month period.
Evaluate outcomes using predefined performance indicators.

Expected Outcomes

Implementation of the NP–RN triage model is expected to achieve measurable improvements, including:

Reduced time from patient arrival to provider assessment
Shorter emergency department length of stay
Fewer patients leaving without being seen
Increased patient satisfaction
Improved emergency department efficiency
Better utilization of available clinical resources

Implications for Evidence-Based Practice

Although comprehensive evidence-based guidelines for emergency department triage models remain limited, the existing literature strongly supports provider-assisted triage as an effective strategy for improving patient flow.

Healthcare organizations should continue implementing and evaluating innovative triage models while generating additional high-quality research. Each implementation contributes valuable evidence that strengthens future emergency department best practices.

Conclusion

Emergency department crowding is unlikely to disappear, making workflow optimization essential for delivering timely, high-quality patient care. Current evidence demonstrates that incorporating a Nurse Practitioner into triage alongside a Registered Nurse can significantly improve patient throughput by reducing wait times, shortening emergency department stays, decreasing patients who leave without treatment, and increasing patient satisfaction. Although additional high-quality research is needed, the available evidence supports the NP–RN triage model as a practical, feasible, and evidence-based approach to improving emergency department operations.

Frequently Asked Questions (FAQs)

What is an NP–RN triage model?

An NP–RN triage model is a collaborative emergency department triage system where a Nurse Practitioner and Registered Nurse jointly assess patients, initiate diagnostics, begin treatment, and discharge eligible low-acuity patients directly from triage.

Why is emergency department crowding a major concern?

ED crowding contributes to longer wait times, treatment delays, increased mortality risk, lower patient satisfaction, and higher rates of patients leaving without receiving medical care.

How does provider-in-triage improve patient flow?

Provider-in-triage models allow diagnostic testing and treatment to begin immediately after triage, reducing delays and improving overall emergency department efficiency.

What evidence supports NP-led triage?

Systematic reviews, randomized controlled trials, and quality improvement studies consistently report shorter emergency department stays, faster provider assessment, lower LWBS rates, and improved patient satisfaction following provider-assisted triage implementation.

Is implementing an NP–RN triage model cost-effective?

Yes. Many emergency departments can implement this model by reallocating existing Nurse Practitioner resources, minimizing additional staffing costs while improving operational efficiency.

What outcomes should hospitals monitor after implementation?

Healthcare organizations should evaluate:

Arrival-to-provider assessment time
Emergency department length of stay
Left Without Being Seen (LWBS) rate
Patient satisfaction scores
Diagnostic turnaround time
Overall patient throughput

Emergency department crowding remains one of the leading causes of delayed patient care. Evidence shows that integrating Nurse Practitioners into triage improves patient throughput by reducing wait times, shortening length of stay, lowering LWBS rates, and increasing patient satisfaction.

Provider-assisted triage enables earlier assessment, diagnostic testing, and treatment initiation, making it one of the most effective operational strategies for improving emergency department efficiency.

Current research supports replacing traditional nurse-only triage with collaborative NP–RN triage teams, particularly in emergency departments experiencing persistent overcrowding.

References

Harding, K. E., Taylor, N. F., & Leggat, S. G. (2011). Do triage systems in healthcare improve patient flow? A systematic review of the literature. Australian Health Review, 35(3), 371–383. https://doi.org/10.1071/AH10927

Hayden, C., Burlingame, P., Thompson, H., & Sabol, V. K. (2014). Improving patient flow in the emergency department by placing a family nurse practitioner in triage: A quality improvement project. Journal of Emergency Nursing, 40(4), 346–351. https://doi.org/10.1016/j.jen.2013.09.011

Holroyd, B. R., Bullard, M. J., Latoszek, K., Gordon, D., Allen, S., Tam, S., Blitz, S., Yoon, P., & Rowe, B. H. (2007). Impact of a triage liaison physician on emergency department overcrowding and throughput: A randomized controlled trial. Academic Emergency Medicine, 14(8), 702–708. https://doi.org/10.1197/j.aem.2007.04.018

Love, R. A., Murphy, J. A., Lietz, T. E., & Jordan, K. S. (2012). The effectiveness of a provider in triage in the emergency department. Advanced Emergency Nursing Journal, 34(1), 65–74. https://doi.org/10.1097/TME.0b013e3182435543

Martin, A., Davidson, C. L., Panik, A., Buckenmyer, C., Delpais, P., & Ortiz, M. (2014). An examination of ESI triage scoring accuracy in relationship to ED nursing attitudes and experience. Journal of Emergency Nursing, 40(5), 461–468. https://doi.org/10.1016/j.jen.2013.09.009

NUR 598 Week 3 Literature Search and Solution

Oredsson, S., Jonsson, H., Rognes, J., Lind, L., Göransson, K. E., Ehrenberg, A., & Farrohknia, N. (2011). A systematic review of triage-related interventions to improve patient flow in emergency departments. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 19(43). https://doi.org/10.1186/1757-7241-19-43

Rowe, B. H., Guo, X., Villa-Roel, C., Schull, M., Holroyd, B., Bullard, M., Vandermeer, B., & Innes, G. (2011). The role of triage liaison physicians on mitigating overcrowding in emergency departments: A systematic review. Academic Emergency Medicine, 18(2), 111–120. https://doi.org/10.1111/j.1553-2712.2010.00984.x

Stover-Baker, B., Stahlman, B., & Pollack, M. (2012). Triage nurse prediction of hospital admission. Journal of Emergency Nursing, 38(3), 306–310. https://doi.org/10.1016/j.jen.2010.12.017

Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau, G., Everett, L. Q., Buckwalter, K. C., Tripp-Reimer, T., & Goode, C. J. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4), 497–509. https://pubmed.ncbi.nlm.nih.gov/11866368/

Welch, S. J. (2012). Using data to drive emergency department design: A metasynthesis. Health Environments Research & Design Journal, 5(3), 26–45. https://doi.org/10.1177/193758671200500305

Wiler, J. L., Gentle, C., Halfpenny, J. M., Heins, A., Mehrotra, A., & Fite, D. (2010). Optimizing emergency department front-end operations. Annals of Emergency Medicine, 55(2), 142–160. https://doi.org/10.1016/j.annemergmed.2009.05.021