Use of Mobile Technologies to Streamline Pretriage Patient Flow in the Emergency Department: Observational Usability Study (Preprint)

Abstract

In emergency departments (EDs), triage nurses are under tremendous daily pressure to rapidly assess the acuity level of patients and log the collected information into computers. With self-service technologies, patients could complete data entry on their own, allowing nurses to focus on higher-order tasks. Kiosks are a popular working example of such self-service technologies; however, placing a sufficient number of unwieldy and fixed machines demands a spatial change in the greeting area and affects pretriage flow. Mobile technologies could offer a solution to these issues.

The aim of this study was to investigate the use of mobile technologies to improve pretriage flow in EDs.

The proposed stack of mobile technologies includes patient-carried smartphones and QR technology. The web address of the self-registration app is encoded into a QR code, which was posted directly outside the walk-in entrance to be seen by every ambulatory arrival. Registration is initiated immediately after patients or their proxies scan the code using their smartphones. Patients could complete data entry at any site on the way to the triage area. Upon completion, the result is saved locally on smartphones. At the triage area, the result is automatically decoded by a portable code reader and then loaded into the triage computer. This system was implemented in three busy metropolitan EDs in Shanghai, China. Both kiosks and smartphones were evaluated randomly while being used to direct pretriage patient flow. Data were collected during a 20-day period in each center. Timeliness and usability of medical students simulating ED arrivals were assessed with the After-Scenario Questionnaire. Usability was assessed by triage nurses with the Net Promoter Score (NPS). Observations made during system implementation were subject to qualitative thematic analysis.

Overall, 5928 of 8575 patients performed self-registration on kiosks, and 7330 of 8532 patients checked in on their smartphones. Referring effort was significantly reduced (43.7% vs 8.8%; <i>P</i>&lt;.001) and mean pretriage waiting times were significantly reduced (4.4, SD 1.7 vs 2.9, SD 1.0 minutes; <i>P</i>&lt;.001) with the use of smartphones compared to kiosks. There was a significant difference in mean usability scores for “ease of task completion” (4.4, SD 1.5 vs 6.7, SD 0.7; <i>P</i>&lt;.001), “satisfaction with completion time” (4.5, SD 1.4 vs 6.8, SD 0.6; <i>P</i>&lt;.001), and “satisfaction with support” (4.9, SD 1.9 vs 6.6, SD 1.2; <i>P</i>&lt;.001). Triage nurses provided a higher NPS after implementation of mobile self-registration compared to the use of kiosks (13.3% vs 93.3%; <i>P</i>&lt;.001). A modified queueing model was identified and qualitative findings were grouped by sequential steps.

This study suggests patient-carried smartphones as a useful tool for ED self-registration. With increased usability and a tailored queueing model, the proposed system is expected to minimize pretriage waiting for patients in the ED.