Patel Pankaj B, Vinson David R
Department of Emergency Medicine, The Permanente Medical Group, Sacramento, CA, USA.
Ann Emerg Med. 2005 Dec;46(6):499-506. doi: 10.1016/j.annemergmed.2005.06.012. Epub 2005 Sep 1.
We designed and implemented an emergency department (ED) team assignment system, each team consisting of 1 emergency physician, 2 nurses, and usually 1 technician. Patients were assigned in rotation upon arrival to a specific team that was responsible for their care. We monitored the time from arrival to physician assessment, percentage of patients who left without being seen by a physician, and patient satisfaction before and after team assignment system implementation.
This study was done in a suburban community hospital with an annual ED census of approximately 39,000. Time to physician assessment was defined from the completion of the medical screening evaluation by an ED nurse at triage to initiation of emergency physician evaluation. Times were documented on the ED paper record and manually entered into a computerized registration by the clerical staff. Patients who left without being seen was reported as percentage of total ED visits. Patient satisfaction scores using a 5-point Likert scale to assess satisfaction with the emergency physician, ED staff courtesy, and coordination of care were gathered every 3 months from random mailings to a subset of patients.
The 12-month ED census was 38,716 before team assignment system implementation and 39,301 afterwards. Complete time data were recorded for 34,152 (88.2%) and 32,537 (82.8%) of the patients, respectively. The mean time to physician assessment was 71.3+/-7.0 minutes before and 61.8+/-6.4 minutes after team assignment system implementation (absolute difference -9.5 minutes; 95% confidence interval [CI] -5.8 to -13.5 minutes). The percentage of patients seen by a physician within 1 hour was 56.3% before and 64.0% after team assignment system implementation (absolute difference 7.7%; 95% CI 5.1% to 10.3%). The percentage of patients who waited more than 3 hours for physician assessment was 17.8% before and 11.8% after team assignment system implementation (absolute difference -6.0%, 95% CI -4.0% to -8.1%). Before team assignment system, the left without being seen rate was 2.3% compared to 1.6% after team assignment system (absolute difference -0.8%; 95% CI -0.4% to -1.1%). Patient satisfaction reported as very good or excellent showed improvement in satisfaction with the physician (absolute increase 3.1%; 95% CI 1.0% to 5.3%), staff courtesy (absolute increase 4.5%; 95% CI 2.3% to 6.7%), and coordination of care (absolute increase 3.6%; 95% CI 0.8% to 6.4%).
The implementation of a team assignment system in our ED was associated with reduced time to physician assessment, a reduced percentage of patients who left without being seen, and improved patient satisfaction.
我们设计并实施了一种急诊科（ED）团队分配系统，每个团队由1名急诊医生、2名护士以及通常1名技术人员组成。患者到达后轮流被分配到特定团队，该团队负责其护理。我们监测了实施团队分配系统前后从患者到达至医生评估的时间、未经医生诊治即离开的患者百分比以及患者满意度。
本研究在一家郊区社区医院进行，该医院急诊科年接诊量约为39000人次。从急诊护士在分诊处完成医疗筛查评估至急诊医生开始评估的时间定义为至医生评估时间。时间记录在急诊科纸质病历上，由文书工作人员手动录入计算机化登记系统。未经诊治即离开的患者以占急诊科总就诊人次的百分比报告。每3个月通过随机邮寄给部分患者的方式收集患者满意度评分，采用5分李克特量表评估对急诊医生、急诊科工作人员礼貌程度以及护理协调的满意度。
在实施团队分配系统前，12个月的急诊科接诊量为38716人次，之后为39301人次。分别有34152例（88.2%）和32537例（82.8%）患者的完整时间数据被记录。实施团队分配系统前至医生评估的平均时间为71.3±7.0分钟，之后为61.8±6.4分钟（绝对差值 -9.5分钟；95%置信区间[CI] -5.8至 -13.5分钟）。实施团队分配系统前1小时内见到医生的患者百分比为56.3%，之后为64.0%（绝对差值7.7%；95% CI 5.1%至10.3%）。实施团队分配系统前等待医生评估超过3小时的患者百分比为17.8%，之后为11.8%（绝对差值 -6.0%，95% CI -4.0%至 -8.1%）。在团队分配系统实施前，未经诊治即离开的比率为2.3%，之后为1.6%（绝对差值 -0.8%；95% CI -0.4%至 -1.1%）。报告为非常满意或优秀的患者满意度在对医生的满意度方面有所提高（绝对增幅3.1%；95% CI 1.0%至5.3%），在工作人员礼貌程度方面（绝对增幅4.5%；95% CI 2.3%至6.7%）以及护理协调方面（绝对增幅3.6%；95% CI 0.8%至6.4%）。
在我们的急诊科实施团队分配系统与缩短至医生评估时间、降低未经诊治即离开的患者百分比以及提高患者满意度相关。
