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Management Brief No. 139

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Management eBriefs
Issue 139December 2017

The report is a product of the VA/HSR Evidence Synthesis Program.

Evidence Map: Effectiveness of Interventions to Improve Emergency Department Efficiency

Crowding in the emergency department (ED) negatively affects patient outcomes, limits effective treatment for time-sensitive conditions such as stroke, myocardial infarction, and sepsis, and reduces the safety and timeliness of care. "Efficiency" in ED care is often assessed by using measures of utilization (i.e., length of stay or waiting time), but in order to be relevant to policymakers it should also include a measure of the unit of resources expended (i.e., number of full-time physicians) to implement the intervention, and some assessment of quality (i.e., number of harms and errors). Many ED efficiency interventions have been described – ranging from structural redesign or staffing changes to technological solutions (i.e., point-of-care lab testing). In order to make decisions on strategic priorities, ED leaders need efficiency intervention studies to:

  • Be clear and specific;
  • Reflect tests in real-world settings;
  • Define the organizational context of the intervention; and
  • Report utilization outcomes, costs, and impacts on quality of care such as harms or errors.

Investigators with VA's Evidence-based Synthesis Program Center located in West Los Angeles, California sought to broadly describe a range of ED efficiency improvement studies using evidence mapping. This approach identifies gaps in knowledge by presenting results in a graphical format to highlight future research needs. First, investigators conducted a literature search in multiple databases (i.e., MEDLINE, 1996 – 7/21/2016, and Cochrane, 2005-7/20/2016) as well as gray literature (not available through the usual bibliographic databases) for peer-reviewed journal articles reporting ED efficiency improvement interventions, including systematic reviews.

Summary of Review
Investigators identified 97 publications that described 17 types of interventions, most commonly physician triage (n=32), nursing scope of practice expansion (n=23), and "fast track" (n=12) that would include strategies to increase the speed with which patients are treated in the ED. Only 3 of 97 studies reported on utilization, resource requirements, costs, and quality measures. Few studies reported the types of data needed to fully assess the effectiveness of efficiency improvement interventions. For example, reporting of ED utilization outcomes varied, with length-of-stay reported by 69% (n=67), wait times by 38% (n=37), and left without being seen by 35% (n=34). Very few studies reported utilization, cost, and quality of care outcomes together, and only a minority of studies quantified the resources required to implement an intervention. Investigators found seven studies that demonstrated improvements in efficiency outcomes solely through reallocating existing resources. These studies represented four different intervention types: physician triage, fast-track, nurse scope of practice expansion, and care teams.

The following evidence map illustrates the distribution of intervention types (x-axis) with resources required for implementation (y-axis). Studies were grouped according to these dimensions and plotted as bubbles, the size of which represented the number of studies in that group. The color of the bubble additionally corresponds to the nature of resource use of a study. A second set of evidence maps, which are available in the full report, depict intervention types (x-axis, major sections), resources required for implementation (color and x-axis, minor sections), effect size (y-axis), and study size (diameter of markers). These maps are not intended to pool data, but to illustrate the evidentiary landscape in regard to interventions to improve ED efficiency.

Evidence Map Displaying Amount of Literature by Intervention and Resource Use Reported:

Evidence Map Displaying Amount of Literature by Intervention and Resource Use Reported (n=97)

Future Research
To better understand the value of ED efficiency interventions, increased measurement and reporting of costs or value-related data is necessary. The large variability in wait times and length-of-stay data also suggests that these may be measured different ways in different studies, and standardization in future work, or more detailed description about these calculations, would be helpful. Most data came from single sites, which may have unique circumstances, so larger studies of multiple sites would increase knowledge in this area. In addition, to better connect theory and practice, a greater understanding of why particular interventions are expected to improve efficiency is needed. Finally, because VA is a unique context with only one publication describing an ED efficiency intervention, more work within VA would be helpful in understanding which of the various interventions might work best in VA's particular circumstances. As healthcare needs continue to increase, EDs are likely to face ever-growing patient loads, so finding and describing the best practices for optimizing ED efficiency remains imperative.

*A cyberseminar session titled "Effectiveness of Interventions to Improve Emergency Department Efficiency: An Evidence Map" will be held on February 26, 2018 from 1:00pm to 2:00pm (ET). Click here to register for this session.

Miake-Lye IM, O'Neil S, Childers C, Gibbons M, Mak S, Shanman R, Beroes JM, Shekelle PG. Effectiveness of Interventions to Improve Emergency Department Efficiency: An Evidence Map. VA ESP Project #05-226; 2017.

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ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.


This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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