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The use of a self-check-in kiosk for early patient identification and queuing in the emergency department
Abstract
Objective
Delays in triage processes in the emergency department (ED) can compromise patient safety. The aim of this study was to provide proof-of-concept that a self-check-in kiosk could decrease the time needed to identify ambulatory patients arriving in the ED. We compared the use of a novel automated self-check-in kiosk to identify patients on ED arrival to routine nurse-initiated patient identification.
Methods
We performed a prospective trail with random weekly allocation to intervention or control processes during a 10-week study period. During intervention weeks, patients used a self-check-in kiosk to self-identify on arrival. This electronically alerted triage nurses to patient arrival times and primary complaint before triage. During control weeks, kiosks were unavailable and patients were identified using routine nurse-initiated triage. The primary outcome was time-to-first-identification , defined as the interval between ED arrival and identification in the hospital system.
Results
Median (interquartile range) time-to-first-identification was 1.4 minutes (1.0–2.08) for intervention patients and 9 minutes (5–18) for control patients. Regression analysis revealed that the adjusted time-to-first-identification was 13.6 minutes (95% confidence interval 12.8–14.5) faster for the intervention group.
Conclusion
A self-check-in kiosk significantly reduced the time-to-first-identification for ambulatory patients arriving in the ED.
... In recent years, this issue has been placed under the spotlight, with numerous solutions proposed to shorten ED waiting times and improve patient outcomes. While some solutions focus on improving management systems, multiple proposals incorporate digital health-namely, the use of self-service kiosks, to assist with patient triage in the ED [5][6][7][8][9][10][11][12][13] . ...
... Kiosks are freestanding devices which resemble ATMs. Patients are prompted to answer algorithm-based questions which allow ED staff to classify their priority level in the queue based on the type and severity of their presenting complaint [5][6][7][8][9][10][11][12][13] . Most kiosks contain a touch screen interface for ease-of-use [7][8][9][10]12 . ...
... Transmitted data is securely stored in external locations such as a hospital database or offsite server to protect patients' confidentiality 7,10 . The goal of these technologies is to support nurse-led manual triaging so that EDs can operate more efficiently [5][6][7][8][9][10][11][12][13] . ...
Triage is a system used to prioritise patients as they enter the emergency department (ED) based on their need for urgent care. In recent decades, EDs have becoming increasingly overcrowded, leading to longer pre-triage waiting times for patients. E-triage interventions like kiosks have been proposed as a solution to overcrowding. We conducted a literature review into the effectiveness of kiosks in improving triage efficiency. After rigorously searching five biomedical databases and screening candidate articles in Endnote, we identified nine papers pertaining to the introduction of kiosks in emergency departments. Six articles had positive findings—with E-triage interventions improving some aspect of the triage process—such as reducing pre-triage times. Conversely, only three articles reported negative findings, such as low uptake. Consequently, EDs should consider introducing kiosks to complement the current nurse-led triage process and thereby promote better patient outcomes.
... Long queues happen in various sectors, i.e., hospitals, banks, and retail stores [2]. In healthcare, taking a long time to book an appointment, get treatment, or take medicine can negatively impact patients' satisfaction and safety [1,[3][4][5][6][7][8]. It is essential to have proper solutions for those long queues in healthcare organizations, where these solutions help to manage the queues along with their related statistics. ...
... For instance, long waiting times in the emergency department can raise the rates of deaths and admission to hospitals, increase patients' complaints and reduce a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 productivity. Despite its widely standard design, it is infrequent to capture patients' arrival time in the triage process [5]. ...
... Also, it confirmed the importance of waiting time for overall patient satisfaction, along with the staff's courtesy and the level of cleanliness. On the other hand, a recent study by [5] provided a proof of concept for achieving early identification for patients in the emergency department using a kiosk for self-check-in. Through a trial with control and intervention weeks, the study proved that the proposed solution could significantly reduce the waiting time for patients before getting treatment in the emergency department. ...
Integration between information systems is critical, especially in the healthcare domain, since interoperability requirements are related to patients’ data confidentiality, safety, and satisfaction. The goal of this study is to propose a solution based on the integration between queue management solution (QMS) and the electronic medical records (EMR), using Health Level Seven (HL7) protocols and Extensible Markup Language (XML). The proposed solution facilitates the patient’s self-check-in within a healthcare organization in UAE. The solution aims to help in minimizing the waiting times within the outpatient department through early identification of patients who hold the Emirates national ID cards, i.e., whether an Emirati or expatriates. The integration components, solution design, and the custom-designed XML and HL7 messages were clarified in this paper. In addition, the study includes a simulation experiment through control and intervention weeks with 517 valid appointments. The experiment goal was to evaluate the patient’s total journey and each related clinical stage by comparing the “routine-based identification” with the “patient’s self-check-in” processes in case of booked appointments. As a key finding, the proposed solution is efficient and could reduce the “patient’s journey time” by more than 14 minutes and “time to identify” patients by 10 minutes. There was also a significant drop in the waiting time to triage and the time to finish the triage process. In conclusion, the proposed solution is considered innovative and can provide a positive added value for the patient’s whole journey.
... Waiting times are a crucial indicator of the effectiveness and quality of medical treatment [24]. Patients may suffer if it takes too long to schedule an appointment, receive treatment, or take medication [1], [23], [25], [26], [27], [28]. For instance, prolonged waiting times in the emergency room can increase the incidence of fatalities, hospital admissions, and patient complaints [26]. ...
... Patients may suffer if it takes too long to schedule an appointment, receive treatment, or take medication [1], [23], [25], [26], [27], [28]. For instance, prolonged waiting times in the emergency room can increase the incidence of fatalities, hospital admissions, and patient complaints [26]. Therefore, having appropriate solutions for those lengthy queues in healthcare organizations is vital, as these solutions aid in managing the queues and the associated statistics. ...
Despite the previous article on technology adoption and the importance of users’ intention to use various technologies in healthcare, users’ acceptance of queue management solutions (QMS) has rarely been measured. The key driver for this article is to evaluate the constructs that have an influence on the acceptance of QMS in the healthcare domain. To achieve this purpose, this article proposes an integrated model based on the integration of various constructs extracted from different theoretical models, including the unified theory of acceptance and use of technology (UTAUT), technology acceptance model (TAM), and social cognitive theory (SCT) along with trust and innovativeness as external factors. The data were collected using an online questionnaire survey from 242 healthcare professionals. The structural equation modeling technique has been employed to validate the model. In general, the results exposed that the suggested model has explained 66.5% of the total variance in the behavioral intention to use QMS. The proposed model is believed to be helpful in exploring the acceptance of other information technologies in the healthcare domain, and the results can provide valuable knowledge to managers and decision-makers in healthcare organizations.
... The use of technological solutions in patient care not only eliminates physical space but also reduces time, optimizing resources. Some hospitals have adopted the use of "self-service kiosks" in different areas, reducing waiting times (Coyle et al., 2019). Furthermore, in the case of a return after the consultation, tools for online scheduling and the availability of necessary information visually can reduce the number of consultations handled by receptionists. ...
The article analyses studies on the impact of the COVID-19 pandemic on outpatient services in a large hospital, aiming to provide insights for resource management amidst disruptive events. The objectives include identifying challenges and proposing solutions to optimize service delivery and address spatial constraints using discrete-event simulation. Utilizing a case study approach, the research employs simulation as a key methodology to analyse outpatient service scenarios. Scenarios are generated by combining different probabilities of patient return to check-in with various team parameterizations. The researchers analysed historical data and key performance indicators from the simulation. The study focuses on a collaborative approach with the hospital team to ensure the relevance and applicability of proposed solutions. The research identifies bottlenecks induced by social distancing measures, particularly in patient reception and check-in areas. Uneven service distribution throughout the day leads to a misallocation of resources and reduction of available physical space. Telemedicine emerges as a significant response, effectively addressing both service optimization and physicians’ workload despite spatial constraints. Additionally, the study underscores the role of simulation in crisis decision-making for hospital operations management. Practical applications emanating from the study emphasize the need for healthcare institutions to adopt adaptable strategies and leverage simulation tools for effective resource management during disruptive events. Hospital administrators can draw insights to inform resource reallocation and workflow optimization, with a focus on negotiating flexible scheduling and exploring telemedicine to enhance service delivery.
... The success of these studies raises the question of how focused, complaint-specific tools may be utilized to optimize triage overall. Kiosk based triage, though largely focused on early registration of patients, has been studied in terms of optimizing efficiency in triage [12,13]. In considering this, it follows that combining kiosk based triage with the development of individual, complaint-focused tools may represent an area for how triage can evolve. ...
Introduction
Canadian patients presenting to the emergency department (ED) typically undergo a triage process where they are assessed by a specially trained nurse and assigned a Canadian Triage and Acuity Scale (CTAS) score, indicating their level of acuity and urgency of assessment. We sought to assess the ability of patients to self-triage themselves through use of one of two of our proprietary self-triage tools, and how this would compare with the standard nurse-driven triage process.
Methods
We enrolled a convenience sample of ambulatory ED patients aged 17 years or older who presented with chief complaints of chest pain, abdominal pain, breathing problems, or musculoskeletal pain. Participants completed one, or both, of an algorithm generated self-triage (AGST) survey, or visual acuity scale (VAS) based self-triage tool which subsequently generated a CTAS score. Our primary outcome was to assess the accuracy of these tools to the CTAS score generated through the nurse-driven triage process.
Results
A total of 223 patients were included in our analysis. Of these, 32 (14.3%) presented with chest pain, 25 (11.2%) with shortness of breath, 75 (33.6%) with abdominal pain, and 91 (40.8%) with musculoskeletal pain. Of the total number of patients, 142 (47.2%) completed the AGST tool, 159 (52.8%) completed the VAS tool and 78 (25.9%) completed both tools. When compared to the nurse-driven triage standard, both the AGST and VAS tools had poor levels of agreement for each of the four presenting complaints.
Conclusions
Self-triage through use of an AGST or VAS tool is inaccurate compared to the established standard of nurse-driven triage. Although existing literature exists which suggests that self-triage tools developed for specific subsets of complaints may be feasible, our results would suggest that adopting the self-triage approach on a broader scale for all-comers to the ED does not appear to be a viable option to enhance the current triage process. Further study is required to show if self-triage can be used in the ED to optimize the triage process.
... 5-8 12-16 Self-check-in kiosks can significantly streamline patient identification and queueing processes, with one study reporting a 14 min reduction in 'time to identification' (arrival to completion of check-in process) with self-check-in. 5 Small time savings in check-in time can lead to significant reductions in overall time-to-triage. In one simulation study, researchers estimated that a check-in time saving through a digital symptom-taking app in a UCC of 2.5 min per patient would decrease waiting time to triage of 26%, while a time saving of 5 min would be associated with a reduction in waiting time of 55%; the researchers described this as more efficient than adding an extra triage nurse. ...
Introduction
Increasing demand for healthcare services worldwide has led to unprecedented challenges in managing patient flow and delivering timely care in emergency care settings. Overcrowding, prolonged waiting times, reduced patient satisfaction and increased mortality are some of the consequences of this increased demand. To address this issue, some healthcare providers have turned to digital systems, such as self-check-in kiosks, for efficient patient triage and prioritisation. While digital triage systems hold promise for efficient patient prioritisation, reduced data duplication, shorter waiting times, improved patient satisfaction, the impact on workflow, the accuracy of triage and staff workload require further exploration for successful implementation in emergency care settings. This systematic review aims to assess the efficacy and safety of digital check-in and triage kiosk implementation within emergency departments.
Methods and analysis
A systematic review will be conducted in MEDLINE (Ovid), Web of Science, Scopus and Science Direct and will include quantitative and mixed method studies with a significant quantitative component, related to self-service kiosk implementation in emergency departments. The outcomes of interest will focus on the efficacy and safety of digital triage, including triage time, workflow, the diagnostic accuracy of triage and adverse events. Risk of bias will be assessed using the Cochrane Risk of Bias Tool. A narrative synthesis will be used to summarise the findings of the included studies.
Ethics and dissemination
This review is exempt from ethical approval because it will be analysing published studies containing non-identifiable data. The findings will be disseminated through peer-reviewed publications.
PROSPERO registration number
CRD42024481506.
... For patients being sent from home to ED, further digital approaches can improve communication and safety, such as transmission of electronic records, vital signs or electrocardiograms of patients from pre-hospital services to ED. [14][15][16][17] Throughput: emergency department assessment and management During ED visits, enabling technologies to facilitate entries of information by patients themselves, such as chatbots or self-service kiosks, are increasingly deployed to accelerate registration. [18][19][20] In addition, we explore two examples of technology-enabled opportunities that can help improve safety and quality of care during patients' ED visits.. ...
... The service industry has been surging with the introduction of kiosks, and developments in touch screen technology have enabled their easy accessibility in daily life [5]. These devices have become common in various public places such as restaurants, subways, museums, shopping malls, hospitals, movie theaters, libraries, and airports, and they are gradually growing in number [1,4,[6][7][8]. ...
Owing to technological advancements, kiosks have become more prevalent in public places. When using such kiosks, elderly persons and people with disabilities face problems related to accessibility and usability, such as difficulties in kiosk operations such as menu selection and in accessing the kiosk space. Previous studies have usually included accessibility as a subset of usability. However, in this study, we aim to redefine the relationship between these two concepts with a focus on newly emerging kiosk devices. First, we performed a literature review to thoroughly analyze these concepts. Then, we conducted a focus group interview (FGI) targeting people with visual, hearing, and physical impairments to learn about the difficulties that these people face when using kiosks. Finally, we analyzed the characteristics of accessibility and usability related to kiosks and designed a diagram that illustrated the relationship between them. While accessibility and usability shared similarities regarding consistency and user control, they differed deeply regarding their subcategory items; many opinions on accessibility were related to essential functions, whereas many on usability were related to psychological factors such as additional functions or personal preferences. These results can be useful when creating laws and guidelines regarding the accessibility and usability of kiosks or when developing kiosk functions.
... To address these deficits, decision support systems are designed to aid laypersons in their self-triage decision-making process, for example, kiosks in the ED [13] or symptom checkers [16]. When using them, around 25% of all patients seem to have reduced perceived urgency of their complaints, and in an experimental study, most participants also followed the advice received by the symptom checkers [17,18]. ...
Background
Although medical decision-making may be thought of as a task involving health professionals, many decisions, including critical health–related decisions are made by laypersons alone. Specifically, as the first step to most care episodes, it is the patient who determines whether and where to seek health care (triage). Overcautious self-assessments (ie, overtriaging) may lead to overutilization of health care facilities and overcrowded emergency departments, whereas imprudent decisions (ie, undertriaging) constitute a risk to the patient’s health. Recently, patient-facing decision support systems, commonly known as symptom checkers, have been developed to assist laypersons in these decisions.
Objective
The purpose of this study is to identify factors influencing laypersons’ ability to self-triage and their risk averseness in self-triage decisions.
Methods
We analyzed publicly available data on 91 laypersons appraising 45 short fictitious patient descriptions (case vignettes; N=4095 appraisals). Using signal detection theory and descriptive and inferential statistics, we explored whether the type of medical decision laypersons face, their confidence in their decision, and sociodemographic factors influence their triage accuracy and the type of errors they make. We distinguished between 2 decisions: whether emergency care was required (decision 1) and whether self-care was sufficient (decision 2).
ResultsThe accuracy of detecting emergencies (decision 1) was higher (mean 82.2%, SD 5.9%) than that of deciding whether any type of medical care is required (decision 2, mean 75.9%, SD 5.25%; t>90=8.4; P89=3.7; P
... Kiosks aided in the provision of acute care in the ED by performing patient triage, reliably collecting patient data, and significantly improving the time to identify new arrivals [72,73]. Other uses in the acute care pathway in the ED included patient registration [74] and medication adherence [75]. ...
Background: Health kiosks are publicly accessible computing devices that provide access to services, including health information provision, clinical measurement collection, patient self–check-in, telemonitoring, and teleconsultation. Although the increase in internet access and ownership of smart personal devices could make kiosks redundant, recent reports have predicted that the market will continue to grow. Objective: We seek to clarify the current and future roles of health kiosks by investigating the settings, roles, and clinical domains in which kiosks are used; whether usability evaluations of health kiosks are being reported, and if so, what methods are being used; and what the barriers and facilitators are for the deployment of kiosks. Methods: We conducted a scoping review using a bibliographic search of Google Scholar, PubMed, and Web of Science databases for studies and other publications between January 2009 and June 2020. Eligible papers described the implementation as primary studies, systematic reviews, or news and feature articles. Additional reports were obtained by manual searching and querying the key informants. For each article, we abstracted settings, purposes, health domains, whether the kiosk was opportunistic or integrated with a clinical pathway, and whether the kiosk included usability testing. We then summarized the data in frequency tables. Results: A total of 141 articles were included, of which 134 (95%) were primary studies, and 7 (5%) were reviews. Approximately 47% (63/134) of the primary studies described kiosks in secondary care settings. Other settings included community (32/134, 23.9%), primary care (24/134, 17.9%), and pharmacies (8/134, 6%). The most common roles of the health kiosks were providing health information (47/134, 35.1%), taking clinical measurements (28/134, 20.9%), screening (17/134, 12.7%), telehealth (11/134, 8.2%), and patient registration (8/134, 6.0%). The 5 most frequent health domains were multiple conditions (33/134, 24.6%), HIV (10/134, 7.5%), hypertension (10/134, 7.5%), pediatric injuries (7/134, 5.2%), health and well-being (6/134, 4.5%), and drug monitoring (6/134, 4.5%). Kiosks were integrated into the clinical pathway in 70.1% (94/134) of studies, opportunistic kiosks accounted for 23.9% (32/134) of studies, and in 6% (8/134) of studies, kiosks were used in both. Usability evaluations of kiosks were reported in 20.1% (27/134) of papers. Barriers (e.g., use of expensive proprietary software) and enablers (e.g., handling of on-demand consultations) of deploying health kiosks were identified. Conclusions: Health kiosks still play a vital role in the health care system, including collecting clinical measurements and providing access to web-based health services and information to those with little or no digital literacy skills and others without personal internet access. We identified research gaps, such as training needs for teleconsultations and scant reporting on usability evaluation methods.
... There is scope for investigation into the role of technology in managing pre-triage wait times. Coyle et al. [23] conducted a prospective randomised trial of self-check-in kiosks at a tertiary care academic hospital in Canada, finding that the median interval between arrival at ED and identification in the hospital system was 1.4 min during weeks where a kiosk was used, compared to 9 min during control weeks. Simulation models (such as that developed by Visintin et al. [8] in their analysis of an anticipated treatment protocol and its effect on pre-triage wait times) present another avenue for the use of technology in intervention development. ...
Background
Pre-triage emergency department (ED) waiting times can be lengthy when presentation numbers are high. Queuing is random, affecting flow management and patient care. We investigated pre-triage wait times and barriers to triage access at an Australian ED.
Methods
A reviewer conducted a retrospective audit of triage reception security video camera footage (February–March, 2020). The reviewer manually documented self-presenting patients’ wait-to-be-seen times and barriers to patient flow.
Results
The audit identified three main topics: lengthy pre-triage wait times, pre-triage queuing and observed barriers to triage. Median pre-triage wait time was 12 min (IQR = 5–21; n = 141), with no apparent relationship between patients’ wait time and time of arrival. During peak or busy periods, multiple random queues formed at the triage reception area. Triage nurses could not concurrently triage and provide queue control during busy periods.
Conclusions
Unrecorded pre-triage wait times may exceed 20 min. This unseen time may extend beyond the estimated post-triage wait times suggested by the Australasian Triage Scale (ATS). There was a degree of disorder in patient queueing, reducing effective door-to-triage productivity. Larger studies could determine these findings’ external replicability, with additional research addressing potential benefits of pre-triage queuing processes or a departmental concierge.
... Worldwide a number of standardised triage tools have a tendency to undertriage, with a substantial proportion of ED patients who die or are critically ill not designated high acuity at triage [13]. There is evidence that self-triage potentially could result in decreased waiting times and reduced amount of face-to-face contact [14,15]. There has been successful use of self-triaging in other departments within hospitals including ophthalmic EDs [16][17][18] and sexual health clinics [19]. ...
Background:
Triage and redirection of patients to alternative care providers is one tool used to overcome the growing issue of crowding in emergency departments (EDs). Electronic patient self-triage (eTriage) may reduce waiting times and required face-to-face contact. There are limited studies into its efficacy, accuracy and validity in an ED setting.
Objectives:
The aim of this study was to assess the agreement and validity of eTriage with a reference standard of nurse face-to-face triage. A secondary aim was to assess the ability of both systems to predict high and low acuity outcomes.
Design:
This was a retrospective study conducted over 8 months in two UK hospitals. Inclusion criteria were all ambulatory patients aged ≥18. All patients completed an eTriage and nurse-led triage using the Manchester Triage System (MTS).
Main results:
During the study period, 43 788 adult patients attended one of the two ED sites and 26 757 used eTriage. A total of 1424 patient episodes had no recorded MTS and were excluded from the study leaving 25 333 paired triages for the final cohort. Agreement between eTriage and nurse triage was low with a weighted Kappa coefficient of 0.14 (95% CI, 0.14-0.15) with an associated weak positive correlation (rs 0.321). Level of undertriage by eTriage compared with nurse triage was 10.1%, and overtriage was 59.2%. The sensitivity for prediction of high acuity outcomes was 88.5% (95% CI, 77.9-95.3%) for eTriage and 53.8% (95% CI 41.1-66.0%) for nurse MTS. The specificity for predicting low risk patients was 88.5% (95% CI, 87.4-89.5%) for eTriage and 80.6% (95% CI, 79.3-81.8%) for nurse MTS.
Conclusion:
Agreement and correlation of eTriage with the reference standard of nurse MTS was low; patients using eTriage tended to over triage when compared to the triage nurse. eTriage had a higher sensitivity for high acuity presentations and demonstrated similar specificity for low acuity presentations when compared to triage nurse MTS. Further work is necessary to validate eTriage as a potential tool for safe redirection of ED attenders to alternative care providers.
... In addition to obtaining a queue number for examination, these patients can enter their medical history, background, pain level, and major complaints data into the system from the kiosk screen (40). Although a limited number of studies have been done on this new practice, the data obtained show that reduced workload helps triage nurses to focus more on patients' medical condition (41), and reduce the waiting time of patients in the ED (42). ...
... In addition to obtaining a queue number for examination, these patients can enter their medical history, background, pain level, and major complaints data into the system from the kiosk screen (40). Although a limited number of studies have been done on this new practice, the data obtained show that reduced workload helps triage nurses to focus more on patients' medical condition (41), and reduce the waiting time (42) of patients in the ED. ...
... Despite the addition of computerization to the process, overcrowding has led to patients in many departments having to wait to be triaged [6]. Risks to patient safety have led some EDs, including the study ED, to put in place processes whereby arriving patients are quickly screened for serious conditions while awaiting formal triage [7]. ...
Background and objective
Emergency departments (EDs) often find the number of arriving patients exceeding their capacity and find it difficult to triage them in a timely manner. The potential risk to the safety of patients awaiting assessment by a triage professional has led some hospitals to consider implementing patient self-triage, such as using kiosks. Published studies about patient self-triage are scarce and information about patients’ ability to accurately assess the acuity of their condition or predict their need to be hospitalized is limited. In this study, we aimed to compare computer-assisted patient self-triage scores versus the scores assigned by the dedicated ED triage nurse (TN).
Methods
This pilot study enrolled patients presenting to a tertiary care hospital ED without ambulance transport. They were asked a short series of simple questions based on an algorithm, which then generated a triage score. Patients were asked whether they were likely to be admitted to the hospital. Patients then entered the usual ED system of triage. The algorithm-generated triage score was then compared with the Canadian Triage and Acuity Scale (CTAS) score assigned by the TN. Whether the patients actually required hospital admission was determined by checking their medical records.
Results
Among the 492 patients enrolled, agreement of triage scores was observed in 27%. Acuity was overestimated by 65% of patients. Underestimation of acuity occurred in 8%. Among patients predicting hospitalization, 17% were admitted, but the odds ratio (OR) for admission was 3.4. Half of the patients with cardiorespiratory complaints were correct in predicting the need for hospitalization.
Conclusion
The use of a short questionnaire by patients to self-triage showed limited accuracy, but sensitivity was high for some serious medical conditions. The prediction of hospitalization was more accurate with regard to cardiorespiratory complaints.
Background
Emergency department (ED) crowding has repercussions on acute care, contributing to prolonged wait times, length of stay, and left without being seen (LWBS). These indicators are regarded as systemic shortcomings, reflecting a failure to provide equitable and accessible acute care. The objective was to evaluate the effectiveness of interventions aimed at improving ED care delivery indicators.
Methods
This was a systematic review and meta‐analysis of randomized controlled trials (RCTs) assessing ED interventions aimed at reducing key metrics of time to provider (TTP), time to disposition (TTD), and LWBS. We excluded disease‐specific trials (e.g., stroke). We used Cochrane's revised tool to assess the risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations to rate the quality of evidence. The meta‐analysis was performed using a random‐effects model and Cochrane Q test for heterogeneity. Data were summarized as means (±SD) for continuous variables and risk ratios (RR) with 95% confidence intervals (CIs).
Results
We searched MEDLINE, EMBASE, and other major databases. A total of 1850 references were scanned and 20 RCTs were selected for inclusion. The trials reported at least one of the three outcomes of TTD, TTP, or LWBS. Most interventions focused on triage liaison physician and point‐of‐care (POC) testing. Others included upfront expedited workup (ordering tests before full evaluation by a provider), scribes, triage kiosks, and sending notifications to consultants or residents. POC testing decreased TTD by an average of 5–96 min (high heterogeneity) but slightly increased TTP by a mean difference of 2 min (95% CI 0.6–4 min). Utilizing a triage liaison physician reduced TTD by 28 min (95% CI 19–37 min; moderate‐quality evidence) and was more effective in reducing LWBS than routine triage (RR 0.76, 95% CI 0.66–0.88; moderate quality).
Conclusions
Operational strategies such as POC testing and triage liaison physicians could mitigate the impact of ED crowding and appear to be effective. The current evidence supports these strategies when tailored to the appropriate practice environment.
Introduction: Emergency department visits have increased substantially, leading to a significant rise in waiting time for patients. Several kiosk-based solutions have been introduced to reduce waiting times in healthcare facilities and to increase efficacy and user satisfaction. Purpose of the Study: This systematic review aims to identify the most effective self-service kiosk features for collecting patients' health information and to evaluate their acceptability among elderly and less educated populations, despite not being the focus, there is pontencial in the development of the system interface to facilitate the perception and understanding of those with less digital literacy. Methods: We conducted a systematic review of studies on diagnosis, replacement of face-to-face consultation, and triage kiosks published between January 2009 and March 2023 in the databases PubMed, IEEE Xplore, Web of Science, Cochrane Library, ScienceDirect, and Scopus. Results: The eight analyzed studies included 2,298 participants in total, with participants aged between 16 and 94 years. Most studies provided kiosk assistance. Elderly patients demonstrated the capability and willingness to participate in technological interventions. Conclusion: User interface elements were the most critical features in health kiosk design, followed by clear communication and patients' understanding of the benefits associated with kiosk use. The high levels of kiosk acceptance and satisfaction observed indicate a significant opportunity for the introduction of self-service kiosks in various healthcare contexts.
Background:
To deal with emergency department (ED) crowding, the American College of Emergency Physicians (ACEP) established a task force to develop a list of low-cost, high-impact solutions. In this study, we report on the trend in the adoption rate of ACEP-recommended ED crowding interventions by US hospitals.
Methods:
We analyzed the National Hospital Ambulatory Medical Care Survey data from 2007 to 2020 (N = 3874 hospitals). The primary outcome was whether a hospital adopted each of the ACEP-recommended interventions, which were grouped into three overlapping categories: technology-based, flow modifications, and physical-based (e.g., changing ED layout).
Results:
On average, the most frequently adopted intervention was bedside registration (85.1%) and the least frequently adopted intervention was kiosk check-in (8.3%). The adoption of ED crowding interventions increased significantly between 2007 and 2020, except for expanding ED treatment space which declined by 45.0% from 30.3% in 2007 to 15.7% in 2020. The largest adoption rate increase occurred in having a separate operating room for ED cases with a 188.5% increase in adoption rate followed by radio-frequency identification (RFID) tracking (151.2%), and kiosk check-in (144.2%).
Conclusions:
The adoption rate of ED crowding interventions by hospitals has risen, however most effective ED crowding interventions are still underutilized. The trends for each intervention did not always increase linearly, with certain periods showing greater fluctuations in adoption rate. Hospitals tend to implement technology-based interventions, compared to physical-based interventions and flow modification interventions.
This case study aims to explore how customer journey concepts can apply to a hypothetical scenario, centring on a patient (customer persona) within the dentistry arena, and with a particular focus on special care dentistry. As an educational exercise, this paper may inform dental and allied professionals on how aspects of the customer journey notion may be embedded into their own practices, so that patient-centricity might be better optimised. The hypothetical scenario considers the organisational context, customer persona, contemporary customer purchase decision-making models, and marketing approaches. These components are used to create a customer journey map to help visualise and identify the varying customer–business interactions. The customer journey, focussing on the awareness, initial consideration, active evaluation, pre-purchase, purchase and post-purchase stages, is then conceptually analysed. The analyses reveal that there are areas of friction, attributable to numerous factors. The case study recommends that by introducing digitalisation and omnichannel marketing, alongside existing internally generated and multi-channel marketing approaches, considerable improvements may be achievable. As the patient technology landscape becomes more digital and dental organisations face fiercer competition, dental care providers relying on traditional marketing approaches may well need to adapt and introduce innovative, yet cost-effective digitalisation and omnichannel marketing approaches. Nevertheless, dental care providers, and dental and allied professionals must uphold an underlying duty of care, ensuring that all practises are legal, decent, honest, truthful, and above all ethical.
Background:
Health kiosks are publicly accessible computing devices that provide access to services, including health information provision, clinical measurement collection, patient self-check-in, telemonitoring, and teleconsultation. Although the increase in internet access and ownership of smart personal devices could make kiosks redundant, recent reports have predicted that the market will continue to grow.
Objective:
We seek to clarify the current and future roles of health kiosks by investigating the settings, roles, and clinical domains in which kiosks are used; whether usability evaluations of health kiosks are being reported, and if so, what methods are being used; and what the barriers and facilitators are for the deployment of kiosks.
Methods:
We conducted a scoping review using a bibliographic search of Google Scholar, PubMed, and Web of Science databases for studies and other publications between January 2009 and June 2020. Eligible papers described the implementation as primary studies, systematic reviews, or news and feature articles. Additional reports were obtained by manual searching and querying the key informants. For each article, we abstracted settings, purposes, health domains, whether the kiosk was opportunistic or integrated with a clinical pathway, and whether the kiosk included usability testing. We then summarized the data in frequency tables.
Results:
A total of 141 articles were included, of which 134 (95%) were primary studies, and 7 (5%) were reviews. Approximately 47% (63/134) of the primary studies described kiosks in secondary care settings. Other settings included community (32/134, 23.9%), primary care (24/134, 17.9%), and pharmacies (8/134, 6%). The most common roles of the health kiosks were providing health information (47/134, 35.1%), taking clinical measurements (28/134, 20.9%), screening (17/134, 12.7%), telehealth (11/134, 8.2%), and patient registration (8/134, 6.0%). The 5 most frequent health domains were multiple conditions (33/134, 24.6%), HIV (10/134, 7.5%), hypertension (10/134, 7.5%), pediatric injuries (7/134, 5.2%), health and well-being (6/134, 4.5%), and drug monitoring (6/134, 4.5%). Kiosks were integrated into the clinical pathway in 70.1% (94/134) of studies, opportunistic kiosks accounted for 23.9% (32/134) of studies, and in 6% (8/134) of studies, kiosks were used in both. Usability evaluations of kiosks were reported in 20.1% (27/134) of papers. Barriers (e.g., use of expensive proprietary software) and enablers (e.g., handling of on-demand consultations) of deploying health kiosks were identified.
Conclusions:
Health kiosks still play a vital role in the health care system, including collecting clinical measurements and providing access to web-based health services and information to those with little or no digital literacy skills and others without personal internet access. We identified research gaps, such as training needs for teleconsultations and scant reporting on usability evaluation methods.
How can patients and their relatives make their concerns heard by healthcare professionals? Many serious adverse events are preceded by patients' worry and concern. This article explores changes in the structures and processes of healthcare that might facilitate safer systems. One important tool might be the ability of patients to become equal partners in the recording of their clinical history.
Background and objectives:
This study aims to characterize check-in kiosk usage within a multidisciplinary ophthalmic clinic.
Patients and methods:
Chart review of patients aged 18 or older seen at Cole Eye Institute, Cleveland Clinic, from August 1, 2019, to October 31, 2019. Primary endpoint was percentage of patients who used a check-in kiosk. Secondary endpoints were demographic characteristics and visual acuity (VA) of the two groups.
Results:
Of 13,752 patients, 3,542 (26%) used a check-in kiosk. Kiosk users were significantly younger than kiosk non-users (median [interquartile range (IQR)]: 63.6 [49.4-72.6] vs. 66.6 [55.0-75.4]; P < .0001), had a lower proportion of Medicaid patients (282 [8%] vs. 930 [10%]; P < .0001), and lived in areas with a greater median income (mean [± standard error]: 54,992 [±236]; P < .0001). On average, they also had better VA (mean ETDRS [95% confidence interval]: 80.5 [80-80.9] vs. 78.3 [78-78.6]; P < .0001).
Conclusions:
Significant demographic and VA differences were observed between kiosk users and non-users and may influence kiosk usage. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:684-690.].
Objectives
Emergency department (ED) lengths of stay are measured from the time of patient registration or triage. The time that patients wait in line prior to registration and triage has not been well described. We sought to characterize pre-triage wait times and compare them to recommended physician response times, as per the Canadian Triage and Acuity Scale (CTAS).
Methods
This observational study documented the time that consenting patients entered the ED and the time that they were formally registered and triaged. Participants’ CTAS scores were collected from the electronic record. Patients arriving to the ED by ambulance were excluded.
Results
A total of 536 participants were timed over 13 separate intervals. Of these, 11 left without being triaged. Participants who scored either CTAS 1 or 2 (n=53) waited a median time of 3.1 (interquartile range [IQR]: 0.43, 11.1) minutes. Patients triaged as CTAS 3 (n=187) waited a median of 11.4 (IQR: 1.6, 24.9) minutes, CTAS 4 (n=139) a median of 16.6 (IQR: 6.0, 29.7) minutes, and CTAS 5 (n=146) a median of 17.5 (IQR: 6.8, 37.3) minutes. Of patients subsequently categorized as CTAS 1 or 2, 20.8% waited longer than the recommended time-to-physician of 15 minutes to be triaged.
Conclusions
All urban EDs closely follow patients’ wait times, often stratified according to triage category, which are assumed to be time-stamped upon a patient’s arrival in the ED. We note that pre-triage times exceed the CTAS recommended time-to-physician in a possibly significant proportion of patients. EDs should consider documenting times to treatment from the moment of patient arrival rather than registration.
Streamlining the triage process is the key in improving emergency department (ED) workflow. Our objective was to determine if parents of pediatric ED patients in, low-literacy, inner-city hospital, who used the audio-assisted bilingual (English/Spanish) self-triage kiosk, were able to enter their child's medical history data using a touch screen panel with greater speed and accuracy than routine nurse-initiated triage.
Parent/child dyads visiting the pediatric ED for nonurgent conditions (February to April 2012) were randomized prospectively to self-triage kiosk group (n = 200) and standard nurse triage group (n = 200). Both groups underwent routine nurse-initiated triage that included verbal elicitation of basic medical history and manual entry into patients' electronic medical records.
The kiosk user was a parent in 88.5% of the cases, a patient (range, 11-17 years) in 9.5% of the cases, and a proxy user (sibling or friend) in 2% of the cases. Language choice for kiosk use was equally distributed (English vs Spanish, 50.5% vs 49.5%). The mean (SD) time to enter medical history data by the kiosk group was significantly shorter than the standard nurse triage group (94.38 [38.61] vs 126.72 [62.61] seconds; P < 0.001). Significant inverse relationship was observed between parent education level and kiosk usage time (r = -0.26; P < 0.001). The mean inaccuracies were significantly lower for kiosk group (P < 0.05) in areas of medical, medication and immunization histories, and total discrepancy score.
Kiosk triage enabled users to enter basic medical triage history data quickly and accurately in an ED setting with future potential for its wider use in improving ED workflow efficiency.
To determine whether patients who are not admitted to hospital after attending an emergency department during shifts with long waiting times are at risk for adverse events.
Population based retrospective cohort study using health administrative databases. Setting High volume emergency departments in Ontario, Canada, fiscal years 2003-7.
All emergency department patients who were not admitted (seen and discharged; left without being seen).
Risk of adverse events (admission to hospital or death within seven days) adjusted for important characteristics of patients, shift, and hospital.
13,934,542 patients were seen and discharged and 617,011 left without being seen. The risk of adverse events increased with the mean length of stay of similar patients in the same shift in the emergency department. For mean length of stay ≥ 6 v <1 hour the adjusted odds ratio (95% confidence interval) was 1.79 (1.24 to 2.59) for death and 1.95 (1.79 to 2.13) for admission in high acuity patients and 1.71 (1.25 to 2.35) for death and 1.66 (1.56 to 1.76) for admission in low acuity patients). Leaving without being seen was not associated with an increase in adverse events at the level of the patient or by annual rates of the hospital.
Presenting to an emergency department during shifts with longer waiting times, reflected in longer mean length of stay, is associated with a greater risk in the short term of death and admission to hospital in patients who are well enough to leave the department. Patients who leave without being seen are not at higher risk of short term adverse events.
Emergency departments in most developed countries have been experiencing significant overcrowding under a regime of severe resource constraints. Physicians in emergency departments increasingly find themselves toiling in workplaces that are characterized by diminished availability of, limited access to, and decreased stability of critical resources. Severe resource constraints have the potential to greatly weaken the overall job satisfaction of emergency physicians. This article examines the impact of hospital resource constraints on the job satisfaction of a large sample of emergency physicians in Canada. After controlling for workflow and patient characteristics and for various institutional and physician characteristics, institutional resource constraints are found to be major contributors to emergency physician job dissatisfaction. Resource factors that have the greatest impact on job satisfaction include availability of emergency room physicians, access to hospital technology and emergency beds, and stability of financial (investment) resources.
This 2-article series offers a conceptual, historical, and moral analysis of the practice of triage. Part I distinguishes triage from related concepts, reviews the evolution of triage principles and practices, and describes the settings in which triage is commonly practiced. Part II identifies and examines the moral values and principles underlying the practice of triage.
A determination of emergency department pre-triage times in patients not arriving by ambulance compared to widely used guideline recommendations – CORRIGENDUM - M. Betz, J. Stempien, S. Trivedi, R. Bryce
Ten years ago, serious overcrowding in emergency departments became a national issue. Although temporary improvement of the problem occurred, the issue of ED overcrowding has now resurfaced and threatens to become worse. Overcrowding is caused by a complex web of interrelated issues described in this article. ED overcrowding has multiple effects, including placing the patient at risk for poor outcome, prolonged pain and suffering of some patients, long patient waits, patient dissatisfaction, ambulance diversions in some cities, decreased physician productivity, increased frustration among medical staff, and violence. Solving the problem of overcrowding will not only require a major financial commitment from the federal government and local hospitals, but will also require a cooperation from managed care. Unless the problem is solved in the near future, the general public may no longer be able to rely on EDs for quality and timely emergency care, placing the people of this country at risk.
As administrators evaluate potential approaches to improve cost, quality, and throughput efficiencies in the emergency department (ED), "front-end" operations become an important area of focus. Interventions such as immediate bedding, bedside registration, advanced triage (triage-based care) protocols, physician/practitioner at triage, dedicated "fast track" service line, tracking systems and whiteboards, wireless communication devices, kiosk self check-in, and personal health record technology ("smart cards") have been offered as potential solutions to streamline the front-end processing of ED patients, which becomes crucial during periods of full capacity, crowding, and surges. Although each of these operational improvement strategies has been described in the lay literature, various reports exist in the academic literature about their effect on front-end operations. In this report, we present a review of the current body of academic literature, with the goal of identifying select high-impact front-end operational improvement solutions.
The authors report on the development and evaluation of a novel patient-centered technology that promotes capture of critical information necessary to drive guideline-based care for pediatric asthma. The design of this application, the asthma kiosk, addresses five critical issues for patient-centered technology that promotes guideline-based care: (1) a front-end mechanism for patient-driven data capture, (2) neutrality regarding patients' medical expertise and technical backgrounds, (3) granular capture of medication data directly from the patient, (4) formal algorithms linking patient-level semantics and asthma guidelines, and (5) output to both patients and clinical providers regarding best practice. The formative evaluation of the asthma kiosk demonstrates its ability to capture patient-specific data during real-time care in the emergency department (ED) with a mean completion time of 11 minutes. The asthma kiosk successfully links parents' data to guideline recommendations and identifies data critical to health improvements for asthmatic children that otherwise remains undocumented during ED-based care.
Recent systematic reviews have noted a lack of evidence that screening for intimate partner violence does more good than harm. We assess whether patients screened for intimate partner violence on a computer kiosk in the emergency department (ED) experienced any adverse events during or subsequent to the ED visit and whether computer kiosk identification and referral of intimate partner violence in the ED setting resulted in safety behaviors or contact with referrals.
We conducted a prospective, observational study in which a convenience sample of male and female ED patients triaged to the waiting room who screened positive (on a computer kiosk-based questionnaire) for intimate partner violence in the past year were provided with resources and information and invited to participate in a series of follow-up interviews. At 1-week and 3-month follow-up visits, we assessed intimate partner violence, safety issues, and use of resources. In addition, to obtain an objective measure of safety, we assessed the number of violence-related 911 calls to participant addresses within a call district 6 months before and 6 months after the index ED visit.
Of the 2,134 participants in a relationship in the last year, 548 (25.7%) screened positive for intimate partner violence. No safety issues, such as calling security or a partner's interference with the screening, occurred during the ED visit for any patient who disclosed intimate partner violence. Of the 216 intimate partner violence victims interviewed in person and 65 contacted by telephone 1 week later, no intimate partner violence victims reported any injuries or increased intimate partner violence resulting from participating in the study. For the sample in the local police district, there was no increase in the number of intimate partner violence victims who called 911 in the 6 months after the ED visit. Finally, 35% (n=131) reported they had contacted community resources during the 3-month follow-up period.
Among patients screening positive for intimate partner violence, there were no identified adverse events related to screening, and many had contacted community resources.
Triage in medicine, part I: concept, history and types
- K V Iverson
- J C Moskop
Iverson KV, Moskop JC. Triage in medicine, part I: concept,
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