Introduction of ‘One Queue’ to our paediatric emergency department (PED)—changing to a single-stream triage destination in PED to improve patient flow, clinician experience and team cohesion.
- data collection
- health services research
- qualitative research
Data availability statement
Data are available upon reasonable request from the main author.
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To provide excellent care for the growing numbers of paediatric emergency departments (PED) presentations, clinicians must have access to paediatric expertise.1 2 There is great variety in the models used to stream children in PEDs—some triage to a single stream which all clinicians work from; others have separate paediatric or emergency queues incorporating emergency department (ED)-based general practitioners (GPs) and nurse practitioners. The authors have experienced various models and felt a single streaming queue would improve training opportunities3 and patient flow4 5 while aiding team cohesion and strengthening the paediatric expertise of those seeing patients in PED6 7—we have termed this new model One Queue (1Q).
We work in a busy London PED within a major trauma centre seeing over 33 000 children annually. Prior to 1Q, patients were triaged to be seen by emergency medicine (EM) clinicians or directly by paediatricians, depending on presentation. This established two discrete teams functioning within PED, fragmenting patient responsibility from the point of triage. Variable waiting times reflected staff availability, causing tension between staff and parents. Children requiring admission were commonly seen by numerous clinicians between teams, increasing the risk of communication errors.8
This model denied clinicians the opportunity to learn from entire patient cohorts—EM staff rarely saw infants or complex paediatric cases; paediatric trainees saw minimal trauma or older children. Such omissions in clinical exposure impact training and confidence, perpetuating the idea that PED patients were either ‘paediatric’ or ‘emergency’ rather than the responsibility of both teams working within that department.
The objectives of this study were to improve care for children attending PED and augment clinician experience through implementing a single-stream triage destination pathway (1Q).
Making a case for change
1Q represented a significant change in intradepartmental flow, senior decision-maker responsibility and admission process. Successful implementation necessitated input from all affected parties to achieve assent and motivation to drive the process (figure 1).
The prospect of initiating 1Q was discussed initially among senior PED figures. The idea was put to the paediatric consultant body and a standard operating procedure (SOP) was drafted. This was discussed with the EM consultants covering PED out of hours (OOH), the paediatric surgical team and nursing leads. Successive alterations were made and iterations were subsequently circulated.
Concerns were raised around staffing, admission process and senior responsibility. Paediatrics feared that as their patient group expanded, EM clinicians may be lost to the adult ED—this was audited informally during the pilot. Similarly, there was a concern that running 1Q OOH with existing paediatric staffing would result in inadequate inpatient ward cover, and so, 1Q functioned during ‘office hours’ until an additional paediatric Senior House Officer (SHO) OOH post was filled.
It was important to establish responsibility for patients in PED. It was agreed this lay with the consultant covering PED in-hours and the on-call EM consultant OOH. This would be transferred to the appropriate subspecialty, paediatrics or paediatric intensive care unit on handover. EM consultants, having varying familiarity with paediatric/neonatal presentations, were supported with departmental teaching and access to consultants from these areas.
Admission rights prior to 1Q lay with the paediatric registrar/consultant and paediatric emergency medicine (PEM) clinical fellow, meaning that EM PEM consultants were required, on occasion, to refer to junior colleagues for admission. 1Q expanded admission rights to the PEM consultant and EM PEM registrar. This was monitored to ensure patients were safely managed on admission. Of note, PEM consultants have additional subspecialty training in PEM and may be from an EM (EM PEM) or paediatric background.
1Q ran for 6 months from September 2019 as a pilot Monday–Friday, 08:00–17:00, with PEM consultant presence in PED. Paediatric and EM staff were surveyed to record expectations and perceived impact prior to initiation and 4 months into the pilot. 1Q continued with these timings following the pilot.
1Q created a single-triage destination, excluding those triaged to the ED-based GP—this pathway remained unaffected (figure 2). Previously, patients under 12 months, reattenders or those likely to require admission were triaged to the ‘paediatric’ queue. This often included complex medical patients or those well-known to paediatrics. The remainder were triaged to EM.
1Q ensured that patients were seen in priority order by the next available clinician irrespective of their background. The requirement for senior paediatric review of specific patient groups remained unchanged, and staff were encouraged to seek advice where appropriate.
The SOP was disseminated to paediatric and EM teams via email, ‘safety huddles’ and departmental teaching. Education was provided in areas clinicians felt uncomfortable—neonatal presentations for EM and minor injuries for paediatricians.
Staff surveyed prior to 1Q felt it would positively impact patient flow and team cohesion and would be beneficial for training, half anticipating greater confidence managing new patient cohorts. Results were borne out by repeat survey 4 months postintroduction, with expected improvements perceived in patient flow and team cohesion, and a greater-than-anticipated effect on training experience and clinical confidence reported—an additional 35% and 47%, respectively, seeing improvement compared with expectation (table 1).
We compared PED performance from September 2018 to February 2019 to the first 6 months of 1Q. These dates were chosen to capture winter peaks, and the significant sustained drop in PED attendance from March 2020 owing to COVID-19 complicated comparison to Spring/Summer 2019 outcomes. During this latter period, PED staffing was affected with paediatric staff redeployed and EM moved to relieve adult ED. Data collected span 24 hours and, thus, also capture results beyond the formal office hours of 1Q.
While there was a 4% increase in attendance during 1Q, we found little difference in admissions or breaches. Time spent in PED also remained similar; however, children were seen appreciably faster during 1Q—a 10% reduction in the time to first clinician, 32% more seen within 30 min and 19% more within the first hour (table 2 and figures 3–8). We anticipate further improvements as staff become used to the new system and as 1Q’s operating times are extended.9
COVID-19 has been demanding for our EM colleagues who were required in adult ED, and we anticipate a similar situation as adult presentations rise again. 1Q prepared paediatrics well for this and facilitated communication between teams to maintain patient flow and safety within PED.
Learning and next steps
Implementing 1Q has long been the ambition of our PED. The appointment of PEM consultants from both PEM and EM routes was vital, providing the skillset to supervise and support PED as well as each other. PEM consultant presence enabled trainees to feel supported and addressed queries about process and flow.
It was essential to start the process well, which meant engaging and motivating stakeholders within paediatrics and EM. Smooth running of 1Q required clear guidance around admission rights and senior oversight. There was concern that, with the advent of shared responsibility for all patients, one team may be left overburdened as staff from the other were redeployed elsewhere. Auditing clinician movement against the rota template and open conversations between teams, facilitated by the PEM consultant, helped allay these concerns.
Given 1Q’s success in-hours, we plan to extend this OOH. Anecdotally, although the 1Q ethos is often adopted OOH, it was felt that there should be consistent presence from both teams in PED to facilitate this. 2021 saw paediatric cover OOH increase, with an additional SHO overnight in PED, prompting a review of 1Q guidance aiming to extend the model.
Finally, we hope that, through sharing our experience, PEDs elsewhere may discuss the benefits of adopting a 1Q-equivalent model.
Data availability statement
Data are available upon reasonable request from the main author.
Patient consent for publication
Twitter @charliehorace, @drlasim
Contributors CG collected and collated the data for this article. The text was written by CG with drafts reviewed and critiqued by LA, HB and RCM.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.