Digital Anticipatory Protocols at Triage to Improve ED Flow.

Implementing Digital Anticipatory Protocols at Triage to Improve Emergency Department Flow: A Before-After Study Protocol

This study aims to evaluate a pre-post intervention adding an early management decision at the end of the triage process to improve patient throughput. The intervention consists of adding digital checkboxes to the electronic triage system, providing nurses with formalized options for anticipated management based on patient acuity. The study compares a pre-intervention phase (May 1st to July 31st, 2026) with a post-intervention phase (May 1st to July 31st, 2027) to naturalize seasonal confounders. The primary outcome is the total Emergency Department Length of Stay (ED LOS).

Study Overview

• Status: Recruiting
• Conditions: Length of Stay; Emergency Department Triage; Workflow; Nurses; Diagnostic Tests; Emergency Department Patient; Emergency Department Crowding
• Intervention / Treatment: Procedure: Digital Anticipatory Protocols at Triage

• Study Type: Observational
• Enrollment (Estimated): 15500

Contacts and Locations

• Study Contact: Name: Thomas Castelain; Phone Number: +41263061392; Email: thomas.castelain@h-fr.ch
• Study Contact Backup: Name: Youcef Guechi; Phone Number: +41263063142; Email: youcef.guechi@h-fr.ch

Study Locations

• Switzerland
  • Canton of Fribourg
    • Villars-sur-Glâne, Canton of Fribourg, Switzerland, 1752
      • Recruiting
      • Fribourg Cantonal Hospital
      • Contact: Thomas Castelain; Phone Number: +41263061392; Email: thomas.castelain@h-fr.ch
      • Contact: Youcef Guechi; Email: youcef.guechi@h-fr.ch
      • Principal Investigator: Youcef Guechi, MD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

The study population comprises all adult patients (over 18 years old) presenting to the emergency department of the cantonal hospital in Fribourg (HFR), Switzerland, during the predefined study periods (Phase 1 and Phase 2). The HFR is a university teaching and research hospital that manages approximately 41,000 ED visits annually.

Description

Inclusion Criteria:

• All patients over 18 years who registered at the admission desk during the study period.

Exclusion Criteria:

• Arrival by emergency medical services (ambulance or helicopter)
• Patient trajectory bypassing the standard nurse-led triage process
• Patient directly referred to another service of the hospital after triage (gynecology, ophthalmology, etc.).

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Phase 1 - Pre-intervention; Patients presenting to the emergency department between May 1st and July 31st, 2026. Patients undergo standard triage assessment performed using the revised Swiss Emergency Triage Scale (SETS). Disposition decisions are monitored using a digital tag in the electronic health records.
Phase 2 - Post-intervention; Patients presenting to the emergency department between May 1st and July 31st, 2027. Patients undergo triage with the addition of a new digital anticipatory protocol. Disposition decisions continue to be monitored using the same digital tag.	Procedure: Digital Anticipatory Protocols at Triage; The intervention consists of adding digital checkboxes to the electronic triage system. This provides nurses with formalized options for anticipated management based on patient acuity, aiming to encourage and document anticipatory actions while stimulating clinical reasoning.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Total Emergency Department Length of Stay (ED LOS).	The time interval from the completion of the patient's administrative registration to their physical departure from the ED	Through completion of the ED visit, up to a maximum of 72 hours.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Left without being seen (LWBS)	Proportion of patients who registered at the ED admission desk and left before receiving a medical screening exam or an evaluation by a physician	Through completion of the ED visit, up to a maximum of 72 hours.
30-day mortality	Assessed through institutional medical records to evaluate safety	Up to 30 days post-ED visit
Intesive Care Unit (ICU) transfers	Proportion of patients transferred to the Intensive Care Unit (ICU) immediately and within 7 days after the ED visit	Up to 7 days post-ED visit

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time From Triage Assessment to Disposition Decision	The time interval, measured in minutes, elapsed from the beginning of the nursing triage assessment to the exact moment a definitive disposition decision (e.g., discharge, admission) is entered by the emergency physician. A disposition decision is operationally defined as the precise moment the attending emergency physician determines that active emergency care is complete. This includes the decision to transfer the patient to a hospital ward (for admissions) or the conclusion of clinical management (for discharges), even if the patient remains in the emergency department awaiting purely logistical arrangements, such as medical transport or family arrival. The measurement tool used to assess and timestamp this outcome is a standardized digital disposition decision tag integrated into the electronic health record.	Through completion of the ED visit, up to a maximum of 72 hours.
Time From Treatment Room Placement to Disposition Decision	The time interval, measured in minutes, elapsed from when the patient is placed in an ED treatment room to the exact moment a definitive disposition decision (e.g., discharge, admission) is entered by the emergency physician. A disposition decision is operationally defined as the precise moment the attending emergency physician determines that active emergency care is complete. This includes the decision to transfer the patient to a hospital ward (for admissions) or the conclusion of clinical management (for discharges), even if the patient remains in the emergency department awaiting purely logistical arrangements, such as medical transport or family arrival. The measurement tool used to assess and timestamp this outcome is a standardized digital disposition decision tag integrated into the electronic health record.	Through completion of the ED visit, up to a maximum of 72 hours.

Collaborators and Investigators

• Sponsor: Hôpital Fribourgeois
• Collaborators: University of Fribourg
• Investigators: Principal Investigator: Youcef Guechi, MD, Hopital Cantonal Fribourgeois (HFR)

Study record dates

Study Major Dates

• Study Start (Actual): May 1, 2026
• Primary Completion (Estimated): July 31, 2027
• Study Completion (Estimated): August 31, 2027

Study Registration Dates

• First Submitted: July 14, 2026
• First Submitted That Met QC Criteria: July 20, 2026
• First Posted (Actual): July 24, 2026

Study Record Updates

• Last Update Posted (Actual): July 24, 2026
• Last Update Submitted That Met QC Criteria: July 20, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Other Study ID Numbers: Req-2026-00230

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED
• IPD Plan Description: Data sharing is restricted by the Swiss Human Research Act and local ethics committee (Swissethics) due to the retrospective/observational nature of this quality improvement project and the lack of explicit patient consent for public open-data sharing.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No