FLOW Hacks 7 – Doc in the Box: Improving Physician Initial Assessment Time in the Emergency Department

In Education & Quality Improvement, Featured, FLOW Hacks by Sachin TrivediLeave a Comment

To continue our FLOW Hacks series, Dr. Joanna Bostwick writes about her team’s innovation aimed at improving physician initial assessment time in the ED.


This intervention was carried out at Hôpital Montfort, Ottawa, Ontario, an academic francophone community hospital with 56, 000 ED visits per year.

Description of the innovation

Our ED has applied an adapted version of Physician in Triage (PIT) termed “Doc in the Box” with the goal of decreasing physician initial assessment times (PIA), length of stay (LOS) and left without being seen rates (LWBS). After patients are triaged and registered, they are seen by an MD in a room adjacent to the waiting room. The physician initial assessment is approximately one minute and determines labs/imaging/pain meds required. These orders are carried out by a dedicated ‘PIA nurse’ and then the patient returns to the waiting room to await follow up assessment in the main ED. Patients may be discharged from this area if the MD believes it is warranted.

Was a quality improvement methodology used?

Statistical Process Control (SPC) charts were used to analyze data.

What Data was used?

Pre and post retrospective study. Baseline (pre) data collected for 20 weeks prior to the intervention. Intervention (post) data collected for 20 weeks (June-Sept 2017). Data collected during the last hour of MD ED shifts.

Who was on the team?

ED Chief
ED QI Director
ED Physicians
Nurse Managers
Resident Physicians

What performance measures were used?


How was it implemented?

This project was a collaboration between emergency physicians, nurse managers, nurses and residents. Initially the MD was positioned at triage with the nurse for a dedicated 5 hours in the evening on the busiest days of the week. This was a pilot project. Since we did not have funding to continue a dedicated MD shift, we decided to have the PIA assessment spread over the afternoon/evening by having this done in the last hour of the shift (1 hour) and to create a dedicated space adjacent to the waiting room.

How did you get buy in from physicians, nurses, administrators and other allied professionals?

Hospital administration had a keen interest in improving performance measures since it is highly linked to funding in Ontario.  Therefore, buy in from administrators and nursing management was straight-forward. In order to get buy in from physicians and nurses, it was important to involve the team in decision-making. Nurses were also happy to have patients seen immediately from the waiting room. Physicians liked that orders were already done by the time the patients entered the main ED as it facilitated disposition.

What impact has it had on your department?

There has been an improvement, overall, with all performance measures. We have also shown that there was no increase in lab utilization (as expected). Physicians believe it improves care and like the process as per our physician survey.

What were some of the barriers to success?

A major barrier was to encourage physicians to do the PIAs at the end of their shift, as they were trying to re-assess patients and ‘cleanup’. However, this was improved by having dedicated nurse to facilitate the process in the PIA room, and physicians liked that it was an easy way to end their shift rather than picking up a new chart.

If you could do it all over again, what changes would you make?

If I could do it again, I would have discussed the plan with the physicians in more depth prior to disseminating the plan with the nurses and nursing management team. It was difficult to implement the intervention when the MDs did not yet have buy-in and were skeptical of the procedure.

This post was copyedited by Jung-In Choi.

Sachin Trivedi

Dr. Trivedi is an Emergency Resident at the University of Saskatchewan. His interests include quality improvement and patient safety, point of care ultrasound and trauma.

David Savage

David Savage is a resident in the FM/EM program at NOSM, Thunder Bay. His interests include EM policy and the application of analytics techniques to physician scheduling, patient forecasting, and capacity planning.