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<!DOCTYPE html> <html lang="en" dir="ltr" xmlns="http://www.w3.org/1999/xhtml" xmlns:mml="http://www.w3.org/1998/Math/MathML"> <head prefix="og: http://ogp.me/ns# article: http://ogp.me/ns/article# book: http://ogp.me/ns/book#" >  <link rel="dns-prefetch" href="//d33xdlntwy0kbs.cloudfront.net" /> <link rel="dns-prefetch" href="//cdn.jsdelivr.net" /> <link rel="dns-prefetch" href="//www.google.com" /> <link rel="dns-prefetch" href="//scholar.google.com" /> <link rel="dns-prefetch" href="//www.googletagmanager.com" /> <link rel="dns-prefetch" href="//rum-static.pingdom.net" /> <meta http-equiv="Content-Type" content="text/html; charset=utf-8" /> <link rel="shortcut icon" href="https://www.medrxiv.org/sites/default/files/images/favicon.ico" type="image/vnd.microsoft.icon" /> <meta name="viewport" content="width=device-width, initial-scale=1" /> <meta name="type" content="article" /> <meta name="category" content="article" /> <meta name="HW.identifier" content="/medrxiv/early/2024/10/18/2024.10.17.24315545.atom" /> <meta name="HW.pisa" content="medrxiv;2024.10.17.24315545v1" /> <meta name="DC.Format" content="text/html" /> <meta name="DC.Language" content="en" /> <meta name="DC.Title" content="Does Practice Match Protocol? Outcomes of More-Acute Emergency Department Patients Seen After Less-Acute Patients Arriving Nearly-Simultaneously" /> <meta name="DC.Identifier" content="10.1101/2024.10.17.24315545" /> <meta name="DC.Date" content="2024-10-18" /> <meta name="DC.Publisher" content="Cold Spring Harbor Laboratory Press" /> <meta name="DC.Rights" content="© 2024, Posted by Cold Spring Harbor Laboratory. This pre-print is available under a Creative Commons License (Attribution-NonCommercial-NoDerivs 4.0 International), CC BY-NC-ND 4.0, as described at http://creativecommons.org/licenses/by-nc-nd/4.0/" /> <meta name="DC.AccessRights" content="restricted" /> <meta name="DC.Description" content="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 dispositional 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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committee/IRB of Northwell Health Institutional Review Board's (IRB's) Human Research Protection Program (IRB #23-0169) exempted ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors." /> <meta name="DC.Contributor" content="Temesgen Tsige" /> <meta name="DC.Contributor" content="Rida Nasir" /> <meta name="DC.Contributor" content="Daisy Puca" /> <meta name="DC.Contributor" content="Kevin Charles" /> <meta name="DC.Contributor" content="Sandhya LoGalbo" /> <meta name="DC.Contributor" content="Lisa Iyeke" /> <meta name="DC.Contributor" content="Lindsay Jordan" /> <meta name="DC.Contributor" content="Melva Morales Sierra" /> <meta name="DC.Contributor" content="David Silver" /> <meta name="DC.Contributor" content="Mark Richman" /> <meta name="article:published_time" content="2024-10-18" /> <meta name="citation_title" content="Does Practice Match Protocol? Outcomes of More-Acute Emergency Department Patients Seen After Less-Acute Patients Arriving Nearly-Simultaneously" /> <meta name="citation_abstract" lang="en" content="<p>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.</p>" /> <meta name="citation_journal_title" content="medRxiv" /> <meta name="citation_publisher" content="Cold Spring Harbor Laboratory Press" /> <meta name="citation_publication_date" content="2024/01/01" /> <meta name="citation_mjid" content="medrxiv;2024.10.17.24315545v1" /> <meta name="citation_id" content="2024.10.17.24315545v1" /> <meta name="citation_public_url" content="https://www.medrxiv.org/content/10.1101/2024.10.17.24315545v1" /> <meta name="citation_abstract_html_url" content="https://www.medrxiv.org/content/10.1101/2024.10.17.24315545v1.abstract" /> <meta name="citation_full_html_url" content="https://www.medrxiv.org/content/10.1101/2024.10.17.24315545v1.full" /> <meta name="citation_pdf_url" content="https://www.medrxiv.org/content/medrxiv/early/2024/10/18/2024.10.17.24315545.full.pdf" /> <meta name="citation_doi" content="10.1101/2024.10.17.24315545" /> <meta name="citation_num_pages" content="22" /> <meta name="citation_article_type" content="Article" /> <meta name="citation_firstpage" content="2024.10.17.24315545" /> <meta name="citation_author" content="Temesgen Tsige" /> <meta name="citation_author_institution" content="Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine" /> <meta name="citation_author_email" content="temesgen12tsige@gmail.com" /> <meta name="citation_author_orcid" content="http://orcid.org/0009-0006-6667-9425" /> <meta name="citation_author" content="Rida Nasir" /> <meta name="citation_author_institution" content="Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine" /> <meta name="citation_author" content="Daisy Puca" /> <meta name="citation_author_institution" content="Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine" /> <meta name="citation_author" content="Kevin Charles" /> <meta name="citation_author_institution" content="Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine" /> <meta name="citation_author" content="Sandhya LoGalbo" /> <meta name="citation_author_institution" content="Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine" /> <meta name="citation_author_orcid" content="http://orcid.org/0009-0007-0479-9824" /> <meta name="citation_author" content="Lisa Iyeke" /> <meta name="citation_author_institution" content="Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine" /> <meta name="citation_author_orcid" content="http://orcid.org/0000-0002-5348-717X" /> <meta name="citation_author" content="Lindsay Jordan" /> <meta name="citation_author_institution" content="Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine" /> <meta name="citation_author" content="Melva Morales Sierra" /> <meta name="citation_author_institution" content="Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine" /> <meta name="citation_author" content="David Silver" /> <meta name="citation_author_institution" content="Northwell Health Glen Cove Hospital, Department of Emergency Medicine" /> <meta name="citation_author" content="Mark Richman" /> <meta name="citation_author_institution" content="Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine" /> <meta name="citation_author_orcid" content="http://orcid.org/0000-0001-8792-6129" /> <meta name="citation_reference" content="Gilboy N, Tanabe P, Travers DA, et al. 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Impact of the implementation of a fast-track on emergency department length of stay and quality of care indicators in the Champagne-Ardenne region: a before–after study. BMJ Open. 2019 Jun 19;9(6):e026200. DOI: https://pubmed.ncbi.nlm.nih.gov/31221873/." /> <meta name="twitter:title" content="Does Practice Match Protocol? Outcomes of More-Acute Emergency Department Patients Seen After Less-Acute Patients Arriving Nearly-Simultaneously" /> <meta name="twitter:site" content="@medrxivpreprint" /> <meta name="twitter:card" content="summary" /> <meta name="twitter:image" content="https://www.medrxiv.org/sites/default/files/images/medrxiv_logo_homepage7-5-small-test-up.png" /> <meta name="twitter:description" content="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 dispositional 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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committee/IRB of Northwell Health Institutional Review Board's (IRB's) Human Research Protection Program (IRB #23-0169) exempted ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors." /> <meta name="og-title" property="og:title" content="Does Practice Match Protocol? Outcomes of More-Acute Emergency Department Patients Seen After Less-Acute Patients Arriving Nearly-Simultaneously" /> <meta name="og-url" property="og:url" content="https://www.medrxiv.org/content/10.1101/2024.10.17.24315545v1" /> <meta name="og-site-name" property="og:site_name" content="medRxiv" /> <meta name="og-description" property="og:description" content="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 dispositional 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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committee/IRB of Northwell Health Institutional Review Board's (IRB's) Human Research Protection Program (IRB #23-0169) exempted ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors." /> <meta name="og-type" property="og:type" content="article" /> <meta name="og-image" property="og:image" content="https://www.medrxiv.org/sites/default/files/images/medrxiv_logo_homepage7-5-small-test-up.png" /> <meta name="citation_date" content="2024-10-18" /> <link rel="alternate" type="text/plain" title="Full Text (Plain)" href="/content/10.1101/2024.10.17.24315545v1.full.txt" /> <link rel="alternate" type="application/pdf" title="Full Text (PDF)" href="/content/10.1101/2024.10.17.24315545v1.full.pdf" /> <meta name="description" content="medRxiv - The Preprint Server for Health Sciences" /> <meta name="generator" content="Drupal 7 (http://drupal.org)" /> <link rel="canonical" href="https://www.medrxiv.org/content/10.1101/2024.10.17.24315545v1" /> <link rel="shortlink" href="https://www.medrxiv.org/node/885379" /> <title>Does Practice Match Protocol? 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class="highwire-article-citation highwire-citation-type-highwire-article node885379" data-node-nid="885379" id="node-885379--21441830072" data-pisa="medrxiv;2024.10.17.24315545v1" data-pisa-master="medrxiv;2024.10.17.24315545" data-apath="/medrxiv/early/2024/10/18/2024.10.17.24315545.atom" data-hw-author-tooltip-instance=""><div class="highwire-cite highwire-cite-highwire-article highwire-citation-medrxiv-article-top clearfix has-author-tooltip" > <h1 class="highwire-cite-title" id="page-title">Does Practice Match Protocol? Outcomes of More-Acute Emergency Department Patients Seen After Less-Acute Patients Arriving Nearly-Simultaneously</h1> <div class="highwire-cite-authors" ><span class="highwire-citation-authors"><span class="highwire-citation-author first hw-author-orcid-logo-wrapper" data-delta="0"><a href="http://orcid.org/0009-0006-6667-9425" target="_blank" class="hw-author-orcid-logo link-icon-only link-icon"><span class="hw-icon-orcid hw-icon-color-orcid"></span> <span class="title element-invisible">View ORCID Profile</span></a><span class="nlm-given-names">Temesgen</span> <span class="nlm-surname">Tsige</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">Rida</span> <span class="nlm-surname">Nasir</span></span>, <span class="highwire-citation-author" data-delta="2"><span class="nlm-given-names">Daisy</span> <span class="nlm-surname">Puca</span></span>, <span class="highwire-citation-author" data-delta="3"><span class="nlm-given-names">Kevin</span> <span class="nlm-surname">Charles</span></span>, <span class="highwire-citation-author hw-author-orcid-logo-wrapper" data-delta="4"><a href="http://orcid.org/0009-0007-0479-9824" target="_blank" class="hw-author-orcid-logo link-icon-only link-icon"><span class="hw-icon-orcid hw-icon-color-orcid"></span> <span class="title element-invisible">View ORCID Profile</span></a><span class="nlm-given-names">Sandhya</span> <span class="nlm-surname">LoGalbo</span></span>, <span class="highwire-citation-author hw-author-orcid-logo-wrapper" data-delta="5"><a href="http://orcid.org/0000-0002-5348-717X" target="_blank" class="hw-author-orcid-logo link-icon-only link-icon"><span class="hw-icon-orcid hw-icon-color-orcid"></span> <span class="title element-invisible">View ORCID Profile</span></a><span class="nlm-given-names">Lisa</span> <span class="nlm-surname">Iyeke</span></span>, <span class="highwire-citation-author" data-delta="6"><span class="nlm-given-names">Lindsay</span> <span class="nlm-surname">Jordan</span></span>, <span class="highwire-citation-author" data-delta="7"><span class="nlm-given-names">Melva Morales</span> <span class="nlm-surname">Sierra</span></span>, <span class="highwire-citation-author" data-delta="8"><span class="nlm-given-names">David</span> <span class="nlm-surname">Silver</span></span>, <span class="highwire-citation-author hw-author-orcid-logo-wrapper" data-delta="9"><a href="http://orcid.org/0000-0001-8792-6129" target="_blank" class="hw-author-orcid-logo link-icon-only link-icon"><span class="hw-icon-orcid hw-icon-color-orcid"></span> <span class="title element-invisible">View ORCID Profile</span></a><span class="nlm-given-names">Mark</span> <span class="nlm-surname">Richman</span></span></span></div> <div class="highwire-cite-metadata" ><span class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">doi:</span> https://doi.org/10.1101/2024.10.17.24315545 </span></div> </div> <div id="hw-article-author-popups-node-885379--21441830072" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">Temesgen Tsige </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>1</span><span class='nlm-institution'>Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine</span>, 270-05 76th Ave., New Hyde Park, NY 11004</div>BS</span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&gs_type=author&author%5B0%5D=Temesgen%2BTsige%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Tsige%20T&link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3ATemesgen%2BTsige%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link"><a href="http://orcid.org/0009-0006-6667-9425" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for Temesgen Tsige</a></li><li class="author-corresp-email-link last"><span>For correspondence: <a href="mailto:temesgen12tsige@gmail.com" class="" data-icon-position="" data-hide-link-title="0">temesgen12tsige@gmail.com</a></span></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">Rida Nasir </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>1</span><span class='nlm-institution'>Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine</span>, 270-05 76th Ave., New Hyde Park, NY 11004</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&gs_type=author&author%5B0%5D=Rida%2BNasir%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Nasir%20R&link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3ARida%2BNasir%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-2"><div class="author-tooltip-name">Daisy Puca </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>1</span><span class='nlm-institution'>Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine</span>, 270-05 76th Ave., New Hyde Park, NY 11004</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&gs_type=author&author%5B0%5D=Daisy%2BPuca%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Puca%20D&link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3ADaisy%2BPuca%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-3"><div class="author-tooltip-name">Kevin Charles </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>1</span><span class='nlm-institution'>Northwell Health Long Island Jewish Medical Center, Department of Emergency Medicine</span>, 270-05 76th Ave., New Hyde Park, NY 11004</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&gs_type=author&author%5B0%5D=Kevin%2BCharles%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Charles%20K&link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AKevin%2BCharles%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search 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Jewish Medical Center, Department of Emergency Medicine</span>, 270-05 76th Ave., New Hyde Park, NY 11004</div>BS</span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&gs_type=author&author%5B0%5D=Lindsay%2BJordan%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Jordan%20L&link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3ALindsay%2BJordan%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-7"><div class="author-tooltip-name">Melva Morales Sierra </div><div class="author-tooltip-affiliation"><span 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this site</a></li></ul></div><div class="author-tooltip-8"><div class="author-tooltip-name">David Silver </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>2</span><span class='nlm-institution'>Northwell Health Glen Cove Hospital, Department of Emergency Medicine</span>, 101 St Andrews Lane, Glen Cove, NY 11542</div>MD</span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&gs_type=author&author%5B0%5D=David%2BSilver%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Silver%20D&link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a 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data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article abstract-view "><span class="highwire-journal-article-marker-start"></span><div class="section abstract" id="abstract-1"><h2 class="">ABSTRACT</h2><div id="sec-1" class="subsection"><p id="p-15"><strong>INTRODUCTION</strong> 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.</p></div><div id="sec-2" class="subsection"><p id="p-16"><strong>MATERIALS AND METHODS</strong> 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.</p></div><div id="sec-3" class="subsection"><p id="p-17"><strong>RESULTS</strong> The study comprised 126 patient pairs (252 patients in total). Overall, there were no statistically-significant differences in dispositional 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%.</p></div><div id="sec-4" class="subsection"><p id="p-18"><strong>CONCLUSION</strong> 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.</p></div></div><h3>Competing Interest Statement</h3><p id="p-19">The authors have declared no competing interest.</p><h3>Funding Statement</h3><p id="p-20">This study did not receive any funding. </p><h3>Author Declarations</h3><p id="p-21">I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.</p><p id="p-22">Yes</p><p id="p-23">The details of the IRB/oversight body that provided approval or exemption for the research described are given below:</p><p id="p-24">Ethics committee/IRB of Northwell Health Institutional Review Board's (IRB's) Human Research Protection Program (IRB #23-0169) exempted ethical approval for this work. </p><p id="p-25">I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.</p><p id="p-26">Yes</p><p id="p-27">I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).</p><p id="p-28">Yes</p><p id="p-29">I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.</p><p id="p-30">Yes</p><div class="section fn-group" id="fn-group-1"><h2>Footnotes</h2><ul><li class="fn-others" id="fn-1"><p id="p-1"><span class="em-link"><span class="em-addr">rnasir1{at}pride.hofstra.edu</span></span> (516) 800-3437</p></li><li class="fn-others" id="fn-2"><p id="p-2"><span class="em-link"><span class="em-addr">daisypuca059{at}gmail.com</span></span> (516) 647-1338</p></li><li class="fn-others" id="fn-3"><p id="p-3"><span class="em-link"><span class="em-addr">kevincharles543{at}gmail.com</span></span> (516) 851-4784</p></li><li class="fn-others" id="fn-4"><p id="p-4"><span class="em-link"><span class="em-addr">slogalbo1{at}pride.hofstra.edu</span></span> (516) 457-0296</p></li><li class="fn-others" id="fn-5"><p id="p-5"><span class="em-link"><span class="em-addr">lisaiyeke{at}gmail.com</span></span> (516) 353-2611</p></li><li class="fn-others" id="fn-6"><p id="p-6"><span class="em-link"><span class="em-addr">ljordan5{at}northwell.edu</span></span> (718) 470-7501</p></li><li class="fn-others" id="fn-7"><p id="p-7"><span class="em-link"><span class="em-addr">mmoralessierra1{at}pride.hofstra.edu</span></span> (516) 366-7520</p></li><li class="fn-others" id="fn-8"><p id="p-8"><span class="em-link"><span class="em-addr">dsilver1{at}northwell.edu</span></span> (516) 674-7300</p></li><li class="fn-others" id="fn-9"><p id="p-9"><span class="em-link"><span class="em-addr">mrichman1{at}northwell.edu</span></span> (310) 309-9257</p></li><li class="fn-others" id="fn-11"><p id="p-11">Mark Richman, Temesgen Tsige and Sandhya LoGalbo: Created data collection tool, performed data collection and entry, integrated those findings and references into the manuscript, reviewed and edited final manuscript.</p></li><li class="fn-others" id="fn-12"><p id="p-12">Patient’s Consent: N/A</p></li><li class="fn-others" id="fn-13"><p id="p-13">Trial/Systematic Review Registry: N/A</p></li></ul></div><div class="section data-availability" id="sec-11"><h2 class="">Data Availability</h2><p id="p-54">All data produced in the present study are available upon reasonable request to the authors. </p></div><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-biorxiv-copyright" > <div class="pane-content"> <div class="field field-name-field-highwire-copyright field-type-text field-label-inline 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