Driving Sustainable Quality Improvement: Long-Term Outcomes of an Emergency Department Triage Redesign

Emergency department (ED) throughput interventions often show short-term gains, yet few address strategies for long-term sustainability in a constantly changing environment. We evaluated the multi-year impact of a triage workflow redesign developed using the dynamic sustainability framework (DSF) to support continuous adaptation.

At our urban public ED within an academic Level I trauma center, a multidisciplinary frontline team implemented a redesigned triage workflow in November 2023 with structured post-implementation processes for ongoing refinement. We operationalized the DSF via bimonthly multidisciplinary check-ins, continuous data review, and monthly report-outs with escalations to the hospital executive team. Outcomes were evaluated across three one-year periods during the post-COVID pandemic era (November 2022-October 2025; pre-, peri-, post-implementation) to control for seasonality. Flow metrics included left without being seen (LWBS), absent without leave (AWOL; patients who were seen by a nurse practitioner or physician but left prior to care completion), and a composite incomplete care (IC) rate: (LWBS+AWOL)/total ED volume. Flow metrics were stratified by age, language, race, and ethnicity. Patient experience measures were assessed as quality indicators. Paired t-tests were used to compare outcomes in corresponding months across periods.

IC did not decrease from pre- to peri-implementation (12.7% to 12.6%, p=0.45) but declined significantly from pre- to post-implementation (12.7% to 9.9%, p<0.01) and peri- to post-implementation (12.6% to 9.9%, p=0.01), driven by LWBS reductions. AWOL increased modestly but did not offset overall IC gains. IC improvements occurred across all demographic subgroups, with narrowing disparities by race, age, and language over time. The LWBS disparity between Black and non-Black patients decreased by 54% across phases (3.3% to 1.5%, p<0.01). Patient experience, including perceived timeliness of care, improved concurrently.

A triage intervention designed with explicit mechanisms for ongoing adaptation was associated with sustained improvements in ED access to care, equity, and patient experience. Proactively embedding strategies for continuous improvement into ED interventions may be critical for maintaining gains in complex, evolving care environments.