RESEARCH

ADVANCED NURSING INTERVENTIONS AND LENGTH

OF STAY IN THE EMERGENCY DEPARTMENT
Author: Mary A. Stauber, DNP, RN, ACNP-BC, Milwaukee, WI

Earn Up to 9.0 CE Hours. See page 318.

Introduction: Over the past 15 years, emergency departments

have become overcrowded, with prolonged wait times and an

extended length of stay (LOS). These factors cause delay in
treatment, which reduces quality of care and increases the
potential for adverse events. One suggestion to decrease LOS in
the emergency department is to implement advanced nursing
interventions (ANIs) at triage. The study purpose was to
determine whether there was a difference in ED LOS between
patients presenting with a chief complaint of abdominal pain
who received ANIs at triage and patients who did not receive
ANIs at triage.
Methods: A retrospective chart review was performed to

determine the ED LOS (mean time in department and mean time

in room [TIR]). The convenience sample included ED patients who
presented to a large Midwestern academic medical centers
emergency department with a chief complaint of abdominal pain

he Institute of Medicine considers ED overcrowding a national epidemic. 1 ED overcrowding

occurs when the volume of ED patients exceeds
the available resources in the emergency department, hospital, or both, causing the emergency department to operate beyond its capacity.2
Multiple factors contribute to ED overcrowding.
Between 1996 and 2006, 425 emergency departments in
the United States closed, yet the number of ED visits
increased from 90.3 million to 119.2 million. As health
care systems evolved, consolidation of duplicate services

Mary A. Stauber is ACNP Option Coordinator/Clinical Faculty, College of

Nursing, Marquette University, and Emergency Nurse Practitioner, Department of Emergency Medicine, Froedtert & Medical College of Wisconsin,
Milwaukee, WI.
For correspondence, write: Mary A. Stauber, DNP, RN, ACNP-BC, Clark
Hall, PO Box 1881, Milwaukee, WI 53201-1881; E-mail: mary.stauber@
marquepptte.edu.
J Emerg Nurs 2013;39:221-5.
Available online 18 May 2012.
0099-1767/$36.00
Copyright 2013 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2012.02.015

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VOLUME 39 ISSUE 3

and Emergency Severity Index level 3. Independent-samples t

tests were used to determine whether there was any statistical
difference in LOS between the two groups. Cohens d statistic
was used to determine effect size.
Results: Implementation of ANIs at triage for patients with low-

acuity abdominal pain resulted in an increased time in department

and a decreased TIR with a medium effect size.
Conclusion: A reduction in TIR optimizes bed availability in the

emergency department. Low-acuity patients spend less time

occupying an ED bed, which preserves limited bed space for the
sickest patients. Results of diagnostic tests are often available by
the time the patient is placed in a room, facilitating early medical
decision making and decreasing treatment time.
Key words: Advanced nursing interventions; Triage guidelines;
Length of stay

occurred and the number of available hospital beds

decreased by 198,000 beds. Other contributing factors
include a decrease in primary care providers, lack of access
to health care, and loss of insurance, which cause individuals to use the emergency departments as their primary
health care provider.1,3
A decrease in the number of emergency departments
and increases in patient volume have lengthened ED wait
time. Wait time is defined as the time between arrival in
the emergency department and the time seen by a provider.
The average wait time for emergent patients to be evaluated
by an ED provider was reported to be 37 minutes, over
double the national recommended maximum time of 15
minutes.4 The median length of stay (LOS) for an emergency visit was reported as 2.6 hours.1,3
Private and government advisory committees and
national organizations have suggested multiple strategies to
minimize treatment delays and facilitate ED throughput.1,5-7 One suggestion to decrease LOS in the emergency
department is to implement advanced nursing interventions
(ANIs) at triage.5,6 ANIs are based on common disease conditions and chief complaints, which allow an emergency
nurse to order select diagnostic tests based on the patients
chief complaint.8 Abdominal pain is one of the most com-

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mon complaints that cause patients to seek medical care.9

However, hemodynamically stable patients with abdominal
pain are considered low acuity and triaged as Emergency
Severity Index (ESI) level 3. Patients with low-acuity
abdominal pain frequently experience delays in receiving
treatment.9,10 ESI level 3 patients make up 30% to 40%
of patients seen in the emergency department and frequently
have an extended LOS in the emergency department.11
Several studies evaluated the use of ANIs, which allow
emergency nurses to order laboratory or radiographic studies or to administer medication at triage based on predetermined protocols.12-15 ANIs have been shown to decrease
time to pain treatment and increase patient comfort,14,16,17
decrease delays in diagnosing and treating critical illnesses,13,15,18 and improve patient satisfaction.12,19 However, there are limited studies that directly measure the
effect of ANIs in decreasing LOS or improving ED
throughput.8,10,12 The purpose of this study was to determine whether there was a difference in ED LOS between
patients who had ANIs and patients who did not.
Definition of Terms

ADVANCED NURSING INTERVENTIONS

ANIs are triage guidelines developed for specific disease

conditions or common complaints that allow an emergency
nurse to initiate diagnostic studies or therapeutic interventions based on the patients chief complaint, triage assessment, and ESI score. ANIs are implemented when there
are no immediate ED beds available, the patient is in stable
condition, and the chief complaint matches one of the
standardized protocols.10 There are no universal ANIs.
Existing ANIs are institution based.
ED LOS

LOS is defined as the number of minutes between the

patients arrival in the emergency department and discharge
from the emergency department.4
EMERGENCY SEVERITY INDEX

The ESI is a standardized 5-level triage scale and acuity categorization tool used to determine priority of care.11,20 ESI
level 1 requires immediate life-saving interventions: airway
protection, emergency medication, or hemodynamic interventions. Criteria for ESI level 2 have 3 possible components: a high-risk situation or potentially unstable patient;
a confused, lethargic, or disoriented patient; or a patient
exhibiting severe pain or distress. ESI levels 3, 4, and 5
are based on resource requirements. Resources are defined
as the number of different types of services a patient will
require (eg, laboratory tests and radiographic studies equal
2 resources). An ESI level 3 patient requires 2 or more

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resources, but the patient is considered in stable condition.

These patients make up 30% to 40% of patients seen in the
emergency department and frequently have an extended stay
in the emergency department. ESI level 4 patients require 1
resource, and ESI level 5 patients require no resources.
Methods

STUDY DESIGN

A retrospective chart review was performed to determine

the time in department (TID) and time in room (TIR)
for patients who received ANIs at triage and those who
did not.
SAMPLE AND SETTING

A convenience sample of ED patients who presented to

a large Midwestern academic medical centers emergency
department during the month of June 2010 between
noon and midnight was reviewed for eligibility. Inclusion
criteria included adult patients aged 18 years or older
with a chief complaint of abdominal pain who were
assigned ESI triage level 3. Exclusion criteria were children aged younger than 18 years, pregnant patients, and
prisoners. The timeframe of noon to midnight was
selected based on an ED census that indicated this was
the busiest period in the emergency department and the
most common time ANIs were implemented. A power
analysis estimated the number of participants needed
per group to be 64 to detect an effect size of 0.50 with
a power of 0.80 and a 95% confidence interval ( =
.05, 2 tailed).21
HUMAN SUBJECTS PROTECTION

The hospital and university institutional review boards

approved the study. To protect patient confidentiality,
all identifying information was removed before aggregation of data.
MEASURES: LOS, TID, AND TIR

The standard definition of LOS is the number of minutes

between the patients arrival in the emergency department
and discharge from the emergency department.4 Both TID
and TIR were the measures used in this study to evaluate
LOS. Time data were obtained from information recorded
in the patients electronic medical record. The time is automatically recorded when the patient arrives in the emergency department, is placed in a room, and departs the
emergency department.
TID is the traditional indicator of LOS in the emergency department, measured from the time the patient
arrives at triage to the time the patient is discharged from
the emergency department.4

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TABLE 1

Demographic data
Variable

ANI group (n = 87)

Non-ANI group (n = 156)

P value

Age [mean (SD)] (y)

Sex [no. (%)]
Male
Female
Race/ethnicity [no. (%)]
White
African American
Hispanic
Other

35 13.31

41 16.78

< .01
.09

22 (25)
65 (75)

56 (36)
100 (64)

33 (38)
46 (53)
6 (7)
2 (2)

69 (44)
73 (47)
9 (6)
5 (3)

.54

TIR, a component of LOS, is measured from the time

the patient is placed in a room to the time the patient is
discharged from the emergency department, excluding time
spent in the waiting room.

TABLE 2

TID and TIR between ANI group and non-ANI

group
ANI group

STUDY PROCEDURES AND DATA ANALYSIS

A list of individuals with a chief complaint of abdominal

pain and an ESI level 3 triage score was obtained from
the monthly ED report. A retrospective chart audit identified patients who presented to the emergency department
between noon and midnight with a chief complaint of
abdominal pain and an ESI level 3 triage score. Patients
were assigned to 1 of 2 groups based on whether ANIs were
implemented at triage. Non-identifying case numbers were
assigned to protect patient privacy and maintain confidentiality. Mean TID and TIR were calculated for each group.
Independent-samples t tests were used to compare the differences in mean TID and TIR between the 2 groups.
Cohens d statistic was used to measure effect size.
Results

Medical records of 272 patients with abdominal pain and

an ESI level 3 score who presented to the emergency
department between noon and midnight were reviewed.
We excluded 29 records: 16 pregnant patients, 10
deceased patients charts that were blocked, and 3 charts
that had incorrect medical record numbers. A total of 243
charts met the inclusion criteria, 87 with ANIs and 156
without ANIs.
Table 1 shows the patient demographic data for the 2
groups. No significant difference in sex was noted between
the 2 groups (t189 = 1.69, P = .09). Women were 3 times
more prevalent than men in both groups. An independentsamples t test found a significant difference between the

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TID [mean (SD)] (min) 584 46.62

TIR [mean (SD)] (min) 332 35.37

Non-ANI group

478 34.23
417 31.17

P < .01.

mean age of the 2 groups (t214 = 2.61, P < .01). The

racial/ethnic distribution was similar for both groups
(t188 = 0.620, P = .54). There were 4 main racial/ethnic
groups: African Americans were the most common group,
followed by white non-Hispanics, then Hispanics, and
finally, a small group consisting of other races/ethnicities.
The mean TID for patients without ANIs was 478
minutes (almost 8 hours). Comparison data indicate that
the mean TID for patients with ANIs was 585 minutes
(9 hours 45 minutes). An independent-samples t test for
unequal variances found a statistically significant difference
between the means of the 2 groups, with t173 = 3.61 and
P < .01 (95% CI, 486.26-542.79). The results indicate
that the ANI group TID (or total LOS) was significantly
longer than the non-ANI group (Table 2).
The mean TIR for patients without ANIs was 417
minutes (almost 7 hours). The mean TIR of patients with
ANIs was 332 minutes (5 hours 32 minutes). An independent-samples t test for unequal variances found a significant difference between the means of the 2 groups, with
t202 = 3.49 and P < .01 (95% CI, 360.75-409.25). The
results indicate that the ANI group spent significantly less
time in the room than the non-ANI group (Table 2). The

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effect sizes for TID and TIR were calculated with Cohens
d statistic, with medium effect sizes for both (0.49 and
0.46, respectively).
Discussion

This study found that implementation of ANIs was not

associated with a decreased TID or overall LOS for patients
with low-acuity abdominal pain. Prior studies have shown
that patients with low-acuity abdominal pain frequently
have an extended LOS in the emergency department.9-11
Abdominal pain is one of the most common chief complaints that cause patients to seek medical care.8 However,
hemodynamically stable patients with abdominal pain are
considered low acuity and are triaged as ESI level 3.
Low-acuity patients make up 30% to 40% of patients seen
in the emergency department and frequently encounter
delays in receiving treatment and have an extended LOS
in the emergency department.9-11
However, ANIs were associated with a decrease in TIR
with a moderate effect size in this study. A reduction in
TIR suggests that ANIs performed at triage were associated
with improved ED patient flow by decreasing delays in
diagnosis. While laboratory tests or radiographic studies
performed at triage are processed, the patient stays in the
waiting room. Low-acuity patients spend less time occupying an ED bed, which optimizes bed availability for the
sickest patients. Results of diagnostic tests are often available by the time the patient is placed in a room, thereby
facilitating early medical decision making. Reduction of
TIR indicates improved efficiency by decreased treatment
time for patients with low-acuity abdominal pain.
Limitations

Several limitations need to be considered. Using a retrospective chart review, one cannot determine causality
between implementation of ANIs and reduced LOS. Other
limitations of the study include the following: data were
collected from a single site, ANI protocols are site-specific
guidelines, and the period for the study was limited to 1
month. These limitations do not take into account variations in internal and external practice or temporal trends.
The facilitys practice style and type of patient population
can influence the external validity of the study. These limitations restrict the studys generalizability.
As noted, there was also a significant difference found
in patient age between the 2 groups. It is unclear whether
the difference in age had any impact on the results.
Further studies should include randomized controlled
trials, evaluation of triage protocols, and development of
standardized pathways or algorithms to ensure appropriate

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ordering of tests. It is important to ensure that patients are

not subjected to unnecessary radiation and do not incur
additional costs for unneeded laboratory tests.
Other questions to consider include the effect of
ANIs on reducing the number of patients who leave without being seen and patients perceptions of ANIs. Patient
satisfaction or dissatisfaction with ANIs may provide additional information to measure quality of care and improve
the process.
Implications for Emergency Nurses

ED overcrowding and limited resources make triage decisions by emergency nurses an extremely important function.
Potential advantages of implementing ANIs at triage include
completion of tests before evaluation by the provider, which
might lead to earlier medical decision making and decrease
treatment time. However, implementing ANIs at triage is a
significant undertaking for emergency nurses. There is the
potential additional responsibility for emergency nurses to
track laboratory results of patients in the waiting room, as
well as follow up on abnormal test results for patients who
leave without being seen. Additional considerations for
implementing ANIs are availability of space, availability of
equipment, and need for dedicated ancillary staff to support
the performance of diagnostic tests at triage.
Conclusions

Despite its limitations, this study suggests that ANIs are

one option to reduce patient TIR and improve ED efficiency. Use of ANIs at triage allows more patients to be
treated by limiting the amount of time low-acuity patients
spend occupying an ED bed.
REFERENCES
1. Institute of Medicine. Hospital-based emergency care: at the
breaking point. http://www.iom.edu/Reports/2006/Hospital-BasedEmergency-Care-At-the-Breaking-Point.aspx. Accessed March 1,
2011.
2. American College of Emergency Physicians. ACEP policy statement:
crowding. www.acep.org/practres.aspx?id=29156. Accessed March 1,
2011.
3. Pitts SR, Niska RW, Xu J, Burt C. National Hospital Ambulatory
Medical Care Survey: 2006 Emergency Department Summary. DHHS
Publication No. 2008-1250. http://www.cdc.gov/nchs/data/nhsr/
nhsr007.pdf. Accessed March 1, 2011.
4. United States Government Accountability Office. Hospital emergency
department: crowding continues to occur, and some patients wait longer
than recommended time frames. GAO-09-347. http://www.gao.gov/
new.items/d09347.pdf. Accessed March 1, 2011.
5. American College of Emergency Physicians. Emergency department
crowding: high impact solutions. http://www.acep.org/WorkArea/
downloadasset.aspx?id=37960. Accessed March 1, 2011.

VOLUME 39 ISSUE 3

May 2013

Stauber/RESEARCH

6. Clinical Advisory Board. The clockwork ED, expediting diagnosis: preemptive test ordering guidelines (volume 2). http://www.
advisory.com/members/default.asp?contentid=40042&collectionid=216&program=5&contentarea=262083. Accessed March 1,
2011.

13. Cooper JJ, Datner EM, Pines JM. Effect of an automated chest radiograph at triage protocol on time to antibiotics in patients admitted with
pneumonia. Am J Emerg Med. 2008;26:264-9.

7. Emergency Nurses Association. Emergency Nurses Association position

statement: crowding in the emergency department. http://www.ena.org/
practice/practpriority/Crowding/Pages/Default.aspx?PF=1. Accessed
March 1, 2011.

15. VanHoy SN, Laskowski-Jones L. Early intervention for the pneumonia

patient: an emergency department triage protocol. J Emerg Nurs.
2006;32:154-8.
16. Campbell P, Dennie M, Dougherty K, Iwaskiw O, Rollo K. Implementation of an ED protocol for pain management at triage at a busy level I
trauma center. J Emerg Nurs. 2004;30:431-8.

8. Wiler JL, Gentle C, Halfpenny JM, et al. Optimizing emergency department front-end operations. Ann Emerg Med. 2010;55:142-60.
9. Swailes E, Rich E, Lock K, Cicotte C. From triage to treatment of
severe abdominal pain in the emergency department: evaluating the
implementation of the emergency severity index. J Emerg Nurs. 2009;
35:485-9.
10. Lee F, Smith S, Jennings N. Low acuity abdominal pain in the
emergency department: still a long wait. Int Emerg Nurs. 2008;
16:94-100.
11. Agency for Healthcare Research and Quality (AHRQ). Emergency
severity index: implementation handbook. Version 4. http://www.
ahrq.gov/research/esi/esi1.htm. Accessed March 1, 2011.
12. Chan TC, Killeen JP, Kelly D, Guss DA. Impact of rapid entry and
accelerated care at triage on reduced emergency department patient wait
times, lengths of stay, and rate of left without being seen. Ann Emerg
Med. 2005;46:491-7.

May 2013

VOLUME 39 ISSUE 3

14. Fosnocht DE, Swanson ER. Use of a triage pain protocol in the ED. Am
J Emerg Med. 2007;25:791-3.

17. Seguin D. A nurse-initiated pain management advanced triage protocol

for ED trauma patients with an extremity injury at a level I trauma
center. J Emerg Nurs. 2004;30:330-5.
18. Graff L, Carlone-Palmer A, LaMonica P, Wolf S. Triage of patients for a
rapid (5-minute) electrocardiogram: a rule based on presenting chief
complaints. Ann Emerg Med. 2000;36:554-65.
19. Kokiko J, Mayer TA. Advanced triage/Advanced interventions: improving patient satisfaction. Top Emerg Med. 1997;19:19-27.
20. Tanabe P, Gimbel R, Yarnold PR, Adams JG. The emergency severity
index 5-level triage system scores predict ED resources consumption.
J Emerg Nurs. 2004;30(1):22-9.
21. Polit DF, Tatano-Beck C. Using inferential statistics to test hypotheses.
In: Nursing Research: Generating and Assessing Evidence for Nursing Practice. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:583-613.

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