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CareSTART: A physician in triage front-end model improves patient safety and ED efficiency

Jamie Santistevan, MD; Andrew Lee, MD; Azita Hamedani, MD, MPH, MBA

Jamie Santistevan_2017Andrew Lee, MDAzita Hamedani, MD, MPH, MBA

There is nationwide recognition that the demand for emergency department services has grown faster than capacity leading to overcrowded EDs and long wait times.1,2 Redesign of front-end processes encompasses many different operational strategies to improve ED throughput and decrease wait times.3 Involving a physician in triage of ED patients is one strategy that allows for rapid discharge of low-acuity patients and rapid sorting and initiation of treatment for the remainder of patients. Published studies of physicians-in-triage demonstrate decreased door-to-assessment time, reduced ED length of stay, and reduced left without being seen (LWBS) rates.4-8


We have recently implemented a triage process called CareSTART that replaces traditional ESI-based nursing triage. CareSTART stands for Safe Timely Assessment and Rapid Treatment. This model utilizes an emergency medicine attending physician as the initial point of patient contact. Through a brief encounter, the CareSTART physician is responsible for determining immediacy of patient needs and next steps in patient care.


Process details
In our process, when an ambulatory patient arrives they are greeted by ‘pivot’ nurse and unit clerk. The patient is quickly registered into our system and their 1-2 word chief complaint for their visit is obtained. Based on the chief complaint and the appearance of the patient, the nurse can ‘pivot’ the patient to the main ED bypassing the CareSTART assessment due to potential critical or time sensitive illness. Otherwise, the CareSTART process continues by having an assigned CareSTART tech obtain vital signs and the patient proceeds to the CareSTART area for physician assessment. The physician then determines the next steps in the care of the patient and sorts patients into the proper queue based on the patient’s needs while a brief history, exam and assessment is documented with the help of a scribe. There are five potential outcomes of the CareSTART physician assessment:

  1. The patient needs immediate attention and a bed in the main ED. The CareSTART physician recognizes a potential life threat, aborts further evaluation and escorts the patient to an ED room giving verbal handoff the next person in the care team. In a typical shift of 50 CareSTART patient encounters this constitutes 2-4%.
  2. The patient urgently needs a bed in the main ED. This patient is sick, or potentially sick, and needs orders for additional testing and treatment and a bed in the main ED on an urgent basis. This constitutes 20-30% of CareSTART encounters.
  3. The patient needs a bed in the main ED but not necessarily immediately. This patient needs testing and treatment initiated but can wait until a bed is available in the main ED. This constitutes 30-40% of CareSTART encounters.
  4. The patient needs some testing and treatment before discharge, but can be managed by an APP in a designated unit. This constitutes 30-40% of CareSTART encounters.
  5. The patient can be discharged home without further testing or treatment. This constitutes 6-10% of CareSTART encounters.

Figure 1: Potential outcomes of CareSTART MD evaluation
Figure 1
: Potential outcomes of CareSTART MD evaluation

The overarching goal of implementing this new front-end operation in our emergency department was to improve the safety of patients in the waiting room by expediting patient care. Faster door-to-physician times means high-acuity, or potential high-acuity, patients are identified earlier and care is initiated earlier. By implementing the CareSTART model, we anticipated that fewer patients would leave the emergency department prior to being seen and that higher acuity patients would spend less time in the waiting room.


Study site
Our emergency department is an academic, level I trauma center with approximately 56,000 ED visits annually. CareSTART is operated daily between 1pm and 10pm, which is the highest volume time of day. During CareSTART hours 90% of patients are evaluated by the CareSTART MD. The remaining 10% are brought in by EMS and are roomed immediately, bypassing CareSTART.


Since implementing CareSTART on November 1, 2016, our emergency department has seen significant improvement in the time that ESI Level 2 patients wait in the waiting room before being roomed and having care initiated. Figure 2 represents the time from arrival to room for ESI Level 2 patients and takes into account all hours of the day (not just when CareSTART is operated). This improvement means that higher acuity patients are spending less time in the waiting room, and getting care they need faster.

Figure 2 - Number of ESI Level 2
Figure 2
: Number of ESI Level 2 ED Patients and Time from Arrival to Room

Additionally, we have seen a decrease in our rates of patients left without being seen (Figure 3). In the preceding three months prior to CareSTART implementation, there were an average of 40 patients/month who left without being seen compared to 15 patients/month in the four months post-implementation.

Figure 3- Number of ED Patients Left Without Being Seen
Figure 3
: Number of ED Patients Left Without Being Seen

Most significantly, the improved operational efficiencies in our front-end processes have resulted in decreased overall length of stay for all our discharged patients (not just those during CareSTART hours). The LOS for all patients discharged from the ED decreased by 19 minutes averaged from November through February. By multiplying this by the number of overall discharged patients on average during that same period, our ED has saved approximately 2,013 minutes per day. Using an average LOS of 242.5 minutes yields an additional 8.3 patients per day that can be seen. This results in anincreased virtual capacity to accommodate about 3,030 additional patients annually.


  Nov 2016 Dec 2016 Jan 2017 Feb 2017 Average
Difference in LOS for d/c patients compared to
same month of the previous year
-16 -24 -24 -11 -18.75
Number of d/c patients for month 3123 3148 3345 3269 3221
Ave LOS for all ED patients 243 237 236 254 242.5

Table 1: ED Length of Stay and ED Discharges between November 2016-February 2017


The benefits of redesigning our ED front-end processes translate to increased operational efficiency and productivity, which ultimately improves the quality and safety of ED practice. By using the new CareSTART model all ambulatory ED patients are evaluated by a physician quickly, higher acuity patients are roomed faster and fewer patients are leaving before being evaluated by a physician. The improved efficiency has resulted in increased capacity, which translates to the ability to see more patients in our ED.



  1. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary. Adv Data 2004:1-34.
  2. Wilson MJ, University GW, Siegel B, University GW, Williams M, Group A. Perfecting Patient Flow: America's Safety Net Hospitals and Emergency Department Crowding. 2005.
  3. Wiler JL, Gentle C, Halfpenny JM, et al. Optimizing emergency department front-end operations. Ann Emerg Med 2010;55:142-60.e1.
  4. Chan TC, Killeen JP, Kelly D, Guss DA. Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, lengths of stay, and rate of left without being seen. Ann Emerg Med 2005;46:491-7.
  5. Terris J, Leman P, O'Connor N, Wood R. Making an IMPACT on emergency department flow: improving patient processing assisted by consultant at triage. Emerg Med J 2004;21:537-41.
  6. Choi YF, Wong TW, Lau CC. Triage rapid initial assessment by doctor (TRIAD) improves waiting time and processing time of the emergency department. Emerg Med J 2006;23:262-5; discussion -5.
  7. Holroyd BR, Bullard MJ, Latoszek K, et al. Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial. Acad Emerg Med 2007;14:702-8.
  8. Partovi SN, Nelson BK, Bryan ED, Walsh MJ. Faculty triage shortens emergency department length of stay. Acad Emerg Med 2001;8:990-5.



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