Emergency department staff opinion on newly introduced phlebotomy services in the department. A cross-sectional study incorporating reflexive thematic analysis.

Emergency department staff opinion on newly introduced phlebotomy services in the department. 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A cross-sectional study incorporating reflexive thematic analysis. Abdi D. Osman, Daryl Yeak, Michael Ben-Meir, George Braitberg This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3939460/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction The demand for Emergency Department (ED) services, both in terms of patient numbers and complexity has risen over the past decades. According to reports, there has been an increase in the ED patient presentation rate from 321 per 1000 to 339 per 1000 between 2017-18 and 2021-22. Consequently, new care models have been introduced to address this surge in demand, mitigate associated risks, and improve overall safety. Among these models is the concept of "front loading" clinical care, involving the initiation of interventions at the point of arrival. This study evaluates the impact of introducing phlebotomists at triage. Method We conducted a cross-sectional survey using purposive sampling and employed quantitative analysis, complemented by reflexive thematic analysis. Results The response rate for the questionnaire was 61% (n = 207) with good representation from all ED craft groups. Nearly all the staff (99.5%) reported being aware of the presence of phlebotomists in the ED, while only 57% of the staff reported working in triage (p = 0.048, 0.0001599 to 0.043073). ‘Valuable/vital resource’ featured as a common response. Early decision making, patient safety, staff and patient satisfaction emerged as consistent themes. Conclusion Emergency Departments continue to introduce new models of care to address increasing demand for services. We present a model that utilises an existing workforce, relocating them from the ambulatory and outpatient setting to the ED and increasing their scope to complement triage needs, including COVID-19 PCR testing, ECG and venous blood gas analysis. Our staff have identified these tasks, and the concierge role provided by the phlebotomists as contributions to enhanced patient care and safety. Phlebotomist Emergency Department Triage Staff staff satisfaction Introduction The demand for Emergency Department (ED) services, in terms of both patient numbers and complexity has continued to grow. In Australia there has been an increase in the ED patient presentation rate from 321 per 1000 to 339 per 1000 between 2017-18 and 2021 − 22 1 . Similar trends have been reported in other countries 2 – 6 . Currently, ED presentations have rebounded to pre-pandemic levels or higher. The underlying causes are multifactorial and encompass increased morbidity from COVID-19 and its complications, morbidity resulting from deferred care, and the progressively aging population 7 , 8 . The increased workload has the potential to compromise patient care 9 – 11 . Consequently, new models have been introduced to manage demand, mitigate risk, and improve safety. Such models include the ability of triage staff to “front load” clinical care and/or interventions 12 . Early point of care testing at triage has been shown to reduce ED length of stay (EDLOS) 13 . However this may come at a cost as it redirects the focus of triage staff from their primary role; which is to triage patients 14 . Most recently, virtual care has the potential to divert patients from visiting an ED 15 – 18 . We report an intervention that allows “front loading” of care to occur while not redirecting triage staff from their core role by introducing phlebotomists at triage to perform blood testing (including venous blood gas (VBG) analysis), LIAT testing for COVID-19 19 and ECGs as directed by triage nurses or medical staff at triage 12 , 17 , 18 . In early 2023, a full-time phlebotomy service with 24/7 coverage was introduced at the ED triage of our health service, a quaternary facility. To assess the impact of this role on patient care and staff satisfaction, we designed a comprehensive mixed method study. Here, we present the findings of our cross-sectional study, which is based on feedback obtained from a muti-disciplinary survey of ED staff and phlebotomists. The main aim of our study was to gather the thoughts and opinions of ED nursing staff, medical personnel, and phlebotomists regarding the role. Method Study design We undertook a voluntary, anonymous, cross-sectional survey at a metropolitan hospital’s ED in Melbourne from 5th October to 11th November 2023, surveying clinical healthcare personnel. The hospital is a quaternary referral facility, and the ED has a mixed (adult, paediatric) annual census of approximately 90,000 patients (about 250 per day). Ethical approval for this study was obtained from the Institution’s Human Research Ethics Committee. Developing the questionnaire In the absence of a validated survey, we designed and developed a customised set of questions and tested them with a group of non-study team members, representing the specific work groups we were targeting, to ensure the questions' effectiveness and acceptability. The final questionnaire was divided into two sections: Part A, which encompassed seven multiple-choice questions focused on socio-demographic details; and Part B, which included seven questions focused on the role of the phlebotomist. Among these, six were multiple-choice questions, some of which involved branch logic, along with open-ended inquiries, while one was entirely open-ended. The closed format questions required an ordinal response or used a five scale Likert ranging from strongly agree to strongly disagree. The collected variables comprised participant information such as gender, age range, discipline or craft group, employment category (full-time/part-time/casual), experience working in triage, and the duration of practice. Inquiries regarding the phlebotomist’s role focused on awareness of the role, experience working alongside a phlebotomist, the role’s impact on expediting patient diagnosis and treatment, whether it enhanced patient safety in the waiting room, its effect on the proportion of patients who did not wait for treatment, and its influence on staff satisfaction. Recruitment Purposive sampling was employed to target a cohort of 340 nurses, doctors, and phlebotomists for participation. Recruitment efforts involved project announcements through the department's weekly electronic newsletter and during staff meetings. The newsletter included a QR code and a link directing individuals to an organizational REDCap site. This site outlined the study's aims and provided instructions on accessing the survey. A plain language statement detailing the study was made available via the provided link. Upon accessing the survey site, staff members were presented with information about the study aims and asked to provide consent. Upon selecting 'yes,' participants gained access to the questionnaire. Data collection Data were collected for about five-week period, from 5th October to 11th November 2023, using online electronic data capture tool (REDCap) hosted by Austin Health. Invitation to participate was sent through the department’s electronic newsletter with a QR code and a link to the survey on the 5th of October 2023, followed by weekly reminders in the newsletter. Data analysis The questionnaire responses were exported to STATA 18e statistical software 20 for analysis. Following exportation to STATA, the open-ended responses were retrieved from the software’s data editor and transcribed into a Microsoft R office 365 Excel spreadsheet. Using a reflexive thematic analysis approach 21 , 22 , after familiarization with the data, each response was coded into a theme. Upon completion of coding by AO, GB and DY convened to review and discuss each theme considering the related quote. In cases where there were discrepancies in codes/themes, the group reached a consensus on which themes to include considering the study aim. Statistics We did not perform a priori sample size calculation since our approach involved purposive sampling, aiming to recruit as many staff members as possible. The favorable response received (~ 61%, n = 207) ensured a study power of over 80%, obviating the need for a post-hoc power calculation. Numerical data are presented as counts and percentages accompanied by 95% confidence intervals (95% CI). In instances of missing values, data are denoted as n (number of cases)/N (total number of instances where the value was known), without making assumptions about the missing data. For non-normally distributed data, differences were assessed using either the one-way ANOVA or two-sample t test, while categorical data differences were evaluated using the Chi-square or Fisher’s exact test, as appropriate. Where there was a need to cross-reference categorical and numerical data, regression tests were used. A two-sided level of significance was set at p < 0.05. Results Participant Information The response rate for the questionnaire was 61% (n = 207) with participant characteristics shown in Table 1 . Staff responses to the questionnaire were one-sided, hence the p value. Table 1 Staff demographic and measure of association with phlebotomist services on diagnosis and treatment. (Pearson/Fisher’s exact) n = 207. Variable Type Frequency P value (CI) Gender Female 162 (78%) P = 0.625 Male 39 (19%) Other 1 Prefer not to say 5 Age group 18 ≤ 25 years 45 (22%) P = 0.393 26 ≤ 35 years 87 (42%) 36 ≤ 45 years 39 (19%) 46 ≤ 55 years 25 (12%) > 55 years 11 (5%) Discipline Nursing 151 (73%) P = 0.823 Med 47(23%) Phlebotomy 9 (4%) Work category Full time 42 (20%) P = 0.944 Part time 151 (73%) Casual 11 (5%) Bank 3 (1%) Do you work in Triage? Yes 117 (57%) P = 0.389 Years of practice Minimum 1 P = 0.715 Mean 17 Maximum 33 Years of practice at Austin Minimum 1 P = 0.415 Mean 13 Maximum 28 Phlebotomists’ role Nearly all the staff (99.5%) reported being aware of the presence of phlebotomists in the ED, while only 57% of the staff reported working in triage (p = 0.048, 0.0001599 to 0.043073). As triage is a specialised area, only suitably trained ED nurses with post-graduate qualifications are able to work at triage and only consultant doctors are able to undertake the “doctor at triage” role known as Multi-Disciplinary Triage (MDT) in our department 12 . However, the high staff awareness attests to the role's impact beyond triage. When surveyed about their perception of the phlebotomist role at triage, most staff (97%) reported finding them to be very supportive, with no differences observed across staff employment categories (p = 0.423), disciplines (p = 0.316), gender (p = 0.614) or years of service (p = 0.122). When asked about the contribution of phlebotomists to improving patient safety, 99.5% of the staff agreed, irrespective of staff discipline (p = 0.066), age groups (p = 0.390) or employment category (p = 0.702) Staff members across all disciplines demonstrated a positive response when asked about their belief in the impact of the phlebotomist's role on expediting patients' diagnosis and treatment (99.5%), enhancing patient safety (99.5%), and reducing instances of patients not waiting for treatment (95%). Furthermore, all responded positively to improvement in staff satisfaction. Thematic analysis of open-ended question. In response to the impact of phlebotomists at triage on staff satisfaction, staff were prompted with an open-ended question to express their views on whether they believed this role enhanced or did not enhance staff satisfaction. The response to the question regarding the impact of phlebotomists on staff satisfaction yielded a unanimous result, with 100% (n = 195) of the participants responding with a ‘yes’. Participants were able to explain the reasoning behind their response in the open-ended question that followed, from which the following five themes emerged (Table 2 ). Among the 195 responses,184 were completed responses available for coding and analysed thematically (supplementary file 1). Table 2 reflexive thematic analysis with frequencies of the themes and selected quotes (n = 184) Theme Frequency of theme Selected quote related code Selected quote Triage specific role focus 37 T024 “1. valuable resource, takes a huge burden off triage and let's triage be able to focus on the patients needs and reassessments. 2. running LIATs and having to wait for the machine to be free, I can be off the floor for 15/20 mins waiting for a machine. which is time I can be used elsewhere. that puts a huge burden on the triage staff whilst I've stepped away. 3. I've definitely stopped ordering bloods and ecg for pts because I know I'll never get to them anytime soon. unless they're a good sounding cardiac chest pain. if you're taking away our resources, why should triage have to work harder to fill the gap.” Expedite treatment decision 45 E010 “Having phlebotomists 24 hours in ED is an amazingly helpful resource. When ED is extremely busy having bloods done allows a baseline to be established before the patient even reaches the cubicle. Sometimes this even allows patients to go home when they are seen by the MDT and frees up a cubicle. Phlebotomists help with patient flow, they start point of care early so therefore a patient breaching in ED is less likely. We need phlebotomists 24/7 in Emergency.” Safety filter against missed opportunities 31 S011 “Respectfully, this is the most perplexing and clearly money driven decision the upper management of this department have ever made. Yet again, another example of asking your staff to do more with less. If you've ever wondered why retention of Critical Care Trained staff is so poor, here is a prime example of why. Triage is the most dangerous and mentally taxing area of the entire department. It is easier to be in charge of the department than it is working at triage, I have ample experience in both. The phlebotomists have been such a valued and integral member of the triage team, and I have no doubt they have saved countless lives because we were able to identify gravely abnormal blood results or ECGs because of their timely and efficient work. They are extremely hard working, always take direction from triage staff and are just very, very good at their role. You simply cannot ask triage nurses who are already struggling to make it through a line that streams out the door and dealing with the cognitive load of unwell patients deteriorating in the WR, to take more onto their already extremely stressful and resource intensive workload. Patients will sit in that waiting room, with high lactates or high troponins to know ones knowledge because they haven't been tested for them. More patients will die. There will be more delays to treatment, department flow will falter and ultimately, you will lose more senior, experienced, highly skilled staff because of this financially driven decision.” Patient satisfaction 26 P003 “- patients more satisfied as they are receiving investigations earlier, and by the time they receive a cubicle or are seen by a clinician they have results available that we can either act upon or discharge them home - patients are therefore more satisfied and less likely to discharge AMA or express anger towards staff - patients grateful that they are being checked up on while they wait - staff are able to then re prioritise patients based on pathology results and act upon these results while the patient awaits a cubicle, as well as detect deterioration earlier, leading to more staff job satisfaction - staff inside the department have more time to then complete additional investigations or assessments once the patient arrives to them.” Increased staff satisfaction 45 IS023 “Having the phelbotomists work in triage has been one of the best changes within the ED since I started here in 2019. They work incredibly hard, they are very efficient and able to complete the bloods/ECGs and LIATs for WR patients much more efficiently and quickly than any nursing staff can. They have boosted the morale of the triage nurses working out there as it takes the stress and worry away from not being able to accomplish said tasks, as more often than not we have a line of patients waiting to be triaged throughout every shift. There has definitely been a huge increase in staff satisfaction and reduction of burn out (personally as well as talking to other nursing staff) since they have been working with us. I am extremely disappointed and concerned for patient safety that they have now only staffed the PM shift.” In a separate open-ended question, the staff were given the opportunity to share additional thoughts or opinions regarding the phlebotomist’s role, specifically in obtaining regular blood tests, blood gases, LIAT for COVID-19 and ECG in triage. Their responses are summarised in Table 3 , with detailed results available in supplementary file 2. Several themes were found to be similar or closely related to those discussed in Table 2 . Table 3 reflexive thematic analysis with frequencies of the themes and selected quotes (n = 139) Theme Frequency of theme Selected quote related code Selected quote Triage specific role focus 17 T008 “Out of all of the areas in ED, triage is where staff feel the most resource poor, and this translates to feelings of stress, frustration and of being overwhelmed. Having 20 people in the waiting room on average (I know it gets lower/higher than this), while staring down a line of people who are in pain, frustrated and unwell waiting to be triaged, the last thing you want to have to do is stop triaging and take 5–10 minutes in order to get the ECG and bloods on the convincing cardiac chest pain you've got in front of you. I can understand that at times the people giving out the funding are most likely to visit are when it is seemingly 'quiet' in the WR, but as someone who has worked in many senior roles, I can honestly say there isn't a harder job in the department than being the MDT or nursing staff working out there. Taking away the phlebotomists will be the straw that breaks a few of these tired, frustrated camels backs. IF the hospital cares about Safewards, KPIs or perhaps even their tired staff during this time, I would strongly suggest NOT taking away one of the very few things that makes the front door of our hospital a workable environment.” Support beyond triage 18 S014 "Having phlebotomists are so important in emergency as when patients come into the cubicles their care has already been started. This is evident if a patient has chest pain and waits in the WR for long periods. When the phlebotomist worked the important blood tests were done + we are able to gather an idea of the severity." Patience/waiting for treatment 20 P007 "The phlebotomists have made a world of change in triage for both the staff and the patients. I have found working in triage less stressful and more streamlined for both staff and patients. I am relieved knowing the patients are getting the tests, procedures and treatment they so desperately need in a timely manner. It is also a weight of my shoulders knowing I am supported as a staff member to provide the best care I can. I also realise the impact it has on the patient's family to know the treatment is being started in the waiting room, and that time spent waiting is not a waste. Please bring back this role on a permanent basis. All the phlebotomists who worked in triage have been lovely to work with and professional in all capacities." Risk mitigation/care escalation 31 R011 "I think the removal of 24hr phlebotomists was a very poor decision and has absolutely no benefit. The outcome of removing this vital role will be poor patient outcomes, including increased agitation and frustration due to longer wait times, and possibly death due to the delay in treatment. This also puts unnecessary pressure on us nurses who are already working under the pump to just be able to perform our regular duties, which will increase stress and burn out. We need our 24 hour phlebotomists in order to effectively care for patients within a timely manner - it shouldn't have to take a patient death for this to be realised." Valuable/vital resource 53 V004 "We need them to become a permanent part of the ED team with fixed EFT, covering all shifts. Early ECG's help mitigate risk factors, allow for downgrading triage categories, or escalating pt care LIAT’s- help us understand cause of symptoms and where to place patients VBG's- allow for immediate results, again escalating care as needed" Discussion The implementation of a phlebotomy service in the ED has not been extensively studied on a large scale, leading to limited availability of literature on this subject. The few centers who have implemented such services over the past decade have reported mixed results 17 , 18 , 23 . We undertook this study to gather staff opinion and thoughts on the phlebotomist’s role in the department. A quantitative observational study of the trial is reported elsewhere. Our staff overwhelmingly expressed appreciation for and support of retaining phlebotomy services within the department. The recruitment and retention of nursing staff in the Emergency Department (ED) have been recognized as a global challenge. According to a study by Cornish 24 , 48.2% of nursing respondents indicated their intention to leave emergency nursing within 5 years. This endorsement from our staff reflects the additional stress placed on triage, especially considering the challenges in recruiting, and retaining experienced staff post-pandemic. Such challenges were noted in some of the free-text comments, exacerbating stressors at triage, “ With such a junior cohort of staff triage is very stressful. Having a phlebotomist allows triage staff to recheck obs, and attend to the usually chaotic WR, taking some of the burden off triage staff”. (IS001) In response to this staffing challenge, it is anticipated that EDs will explore additional support services beyond the traditional nursing and medical workforce. Some have introduced paramedics, while others have employed other technicians in the ED 25 , 26 . We believe that phlebotomists should be considered an integral part of the new ED staffing workforce matrix. Staff reflected the additional stress this placed on triage by stating, “ Because pathology results are returned earlier identifying potentially life-threatening conditions. Triage is already an enormously stressful area to work and having 40 + patients with unknown clinical conditions only adds to the stress of staff. Trying to find time to do path on patients you are concerned about whilst also navigating an endless stream of new patients to triage is near impossible. Having the pathology staff has decreased the anxiety levels of staff working at triage ”. (S005) Despite only 57% of our study participants directly working in triage, the phlebotomists’ roles had a far-reaching impact across the entire department. This is evidenced by the overwhelming positive response regarding the substantial impact they have made in the department. Staff acknowledged the phlebotomists’ contribution beyond triage (S014, Table 3 ) and recognition of their value in the department with one participant stating, "The are absolutely ESSENTIAL to the workings of this department. The have a huge impact on flow as results are back before the patients even hit the cubicles in most cases and plans can immediately be put into place re disposition. There are zero negatives having phlebotomists working at triage 24/7”. (V006) The themes presented in Tables 2 and 3 broadly captured the elements which are essential for staff and patients’ satisfaction and wellbeing. The theme “triage specific role focus” highlighted the liberation of triage staff from additional obligations, enabling them to concentrate solely on the task of triaging as mentioned by T015, “- supports triage nurses to continue triaging instead of attending to path/ECGs which can delay treatment/getting through triage line”. The staff have repeatedly mentioned triage should be for triaging patients only as they shared their concerns on the unstable patients in the long triage cues 14 , 27 , 28 . The themes “expedite treatment decision” and “support beyond triage” emphasises the importance of prompt initiation of investigations. Patients frequently experience prolonged waiting periods in the waiting room. By commencing these investigations early, waiting time for results is reduced. This ensures that when patients are due to be seen, the results are more readily available for informed decision-making and treatment planning. This enhances both provider and patient satisfaction and reduces the proportion of those who opt not to wait for treatment 29 . The themes on “safety filter against missed opportunities” and “risk mitigation/care escalation” builds upon expediting treatment decision, a core component of which is availability of investigations that may identify undetected critical conditions. Following the introduction of venous blood gas analysis by the phlebotomists we identified 18 episodes where conditions such as electrolyte disturbances were identified early leading to a clinically significant change in care. This has been identified previously 30 . “Patient satisfaction” and patience/waiting for treatment” themes focus on an important person-centered outcome indicator. These themes emerged as all-encompassing with various elements contributing to patient contentment mentioned. With long waiting time in ED waiting rooms, initiating investigations early by the phlebotomists under supervision of the triage nurses is believed to be reassuring for patients, leading to a reduction in patient enquiries at the triage window. This proactive approach reduces patient’s aggression towards staff due to lengthy waits and positively impacts patients’ decision to wait for treatment rather than also leaving due to prolonged waiting times 31 . Overall, it contributes to a more positive patient experience in the waiting room. The themes “increased staff satisfaction” and “valuable/vital resources” elaborates on how the activities of the phlebotomist contribute to enhancing staff morale at triage and beyond. Staff members working in the emergency cubicles expressed considerable appreciation for receiving patients who have already undergone preliminary investigations. This situation expedites patient treatment and streamlines the flow of patients through the system, positively impacting overall staff satisfaction. The recognition of this support in expediting patient care in triage and beyond contributes significantly to staff morale and satisfaction 32 . Limitations The study has the following limitations: Firstly, the absence of a pre-validated survey tool meeting our specific objectives necessitated the creation of an individual survey tool for a singular time-point use. Secondly, the study was conducted at a single site, potentially restricting its external validity. Thirdly, While the overwhelmingly positive results in some instances may suggest a biased sample, the large response rate (61%) would mitigate against this. Conclusion Emergency Departments continue to seek new models of care to deal with increasing demand. We present a model that utilises an existing workforce, reallocated them from the ambulatory and outpatient setting to the ED and increasing their scope to complement triage needs, namely COVID-19 PCR testing, ECG and venous blood gas analysis. Our staff have identified these tasks, and the concierge impact of the phlebotomists as a role that enhances patient care and safety. Specifically, alleviating triage staff from additional responsibilities associated with providing patient care in the waiting room, holds the promise of enhancing triage services to patients, improving both pace and accuracy of triaging. Staff expressed satisfaction that patient care now begins in the waiting room, particularly after extended waiting periods and before bed allocation. This improvement, they believe contributes to timely treatment and disposition decisions, and increased patient satisfaction. Abbreviations ED- Emergency Department EDLOS- Emergency Department Length of Stay ECG- Electro Cardiography Declarations Ethics approval and consent to participate – Ethics approval was obtained from the Organizational Human Research Ethics Committee reference HREC/101323/Austin-2023. Consent was obtained from the participants. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Consent for publication - Both ethics and participants were informed of the intention to publish. Availability of data and materials – Data submitted as supplementary files. Questionnaire can be shared from REDCap data dictionary where reasonable request is submitted. Competing interests – No competing interest to declare. Funding – The study did not receive any funding at any stage. Authors' contributions – All authors have equally contributed. Acknowledgements - We acknowledge the participants of this survey who, despite their usually busy work, found the time to provide responses to our questionnaire. References Australian Institute of Health and Welfare. Emergency department care activity. . 2023. https://www.aihw.gov.au/reports-data/myhospitals/intersection/activity/ed#:~:text=Over%20time%2C%20the%20number%20of,339%20presentations%20in%202021%E2%80%9322. Aboagye-Sarfo P, Mai Q, Sanfilippo FM, Preen DB, Stewart LM, Fatovich DM. Growth in Western Australian emergency department demand during 2007–2013 is due to people with urgent and complex care needs. 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Journal of Clinical Nursing . 2023;32(17-18):5461-5477. doi:https://doi.org/10.1111/jocn.16622 Van Der Linden MC, Van Loon-Van Gaalen M, Richards JR, Van Woerden G, Van Der Linden N. Effects of process changes on emergency department crowding in a changing world: an interrupted time-series analysis. International Journal of Emergency Medicine . 2023/02/15 2023;16(1):6. doi:10.1186/s12245-023-00479-z Joseph MJ, Summerscales M, Yogesan S, Bell A, Genevieve M, Kanagasingam Y. The use of kiosks to improve triage efficiency in the emergency department. npj Digital Medicine . 2023/02/03 2023;6(1):19. doi:10.1038/s41746-023-00758-2 Metro South Health. Phlebotomists assisting patients at QEII ED . 2019. https://metrosouth.health.qld.gov.au/news/phlebotomists-assisting-patients-at-qeii-ed Stowell JR, Pugsley P, Jordan H, Akhter M. Impact of Emergency Department Phlebotomists on Left-Before-Treatment-Completion Rates. West J Emerg Med . 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Is COVID-19 the straw that broke the back of the emergency nursing workforce? Emerg Med Australas . Dec 2021;33(6):1095-1099. doi:10.1111/1742-6723.13843 Pourmand A, Caggiula A, Barnett J, Ghassemi M, Shesser R. Rethinking Traditional Emergency Department Care Models in a Post-Coronavirus Disease-2019 World. Journal of Emergency Nursing . 2023/07/01/ 2023;49(4):520-529.e2. doi:https://doi.org/10.1016/j.jen.2023.02.008 Powers R. Paramedics in the emergency department. J Emerg Nurs . Jun 2007;33(3):199-200. doi:10.1016/j.jen.2007.02.012 Riedel HB, Espejo T, Bingisser R, Kellett J, Nickel CH. A fast emergency department triage score based on mobility, mental status and oxygen saturation compared with the emergency severity index: a prospective cohort study. QJM: An International Journal of Medicine . 2023;116(9):774-780. doi:10.1093/qjmed/hcad160 Abu-Alhaija DM, Johnson KD. The emergency nurse responses to triage interruptions and how these responses are perceived by patients: An observational, prospective study. International Emergency Nursing . 2023/03/01/ 2023;67:101251. doi:https://doi.org/10.1016/j.ienj.2022.101251 Faber J, Coomes J, Reinemann M, Carlson JN. Creating a Rapid Assessment Zone with Limited Emergency Department Capacity Decreases Patients Leaving Without Being Seen: A Quality Improvement Initiative. Journal of Emergency Nursing . 2023/01/01/ 2023;49(1):86-98. doi:https://doi.org/10.1016/j.jen.2022.10.002 Baugh CW, Freund Y, Steg PG, Body R, Maron DJ, Yiadom MYAB. Strategies to mitigate emergency department crowding and its impact on cardiovascular patients. European Heart Journal Acute Cardiovascular Care . 2023;12(9):633-643. doi:10.1093/ehjacc/zuad049 Robinson S. Maintaining a safe environment in emergency department waiting rooms. Emerg Nurse . Dec 19 2023;doi:10.7748/en.2023.e2189 Hwang S, Shin S. Factors affecting triage competence among emergency room nurses: A cross-sectional study. Journal of Clinical Nursing . 2023;32(13-14):3589-3598. doi:https://doi.org/10.1111/jocn.16441 Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.Thematicanalysis.xlsx Supplementaryfile2.Thematicanalysis.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3939460","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":272542508,"identity":"ecfafa74-9184-4b89-8647-081824327e05","order_by":0,"name":"Abdi D. Osman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYDACCQaDAxAWM5hmbCBBC1sC8VqgLB4D4rTwz27eeIChoi6af3bPN2keBhvZDQeYn0ngteTOsYIDDGcO5864c3YbUEua8YYDbGZ4tTDcyDE4wNh2ILfhRu5mYx6Gw4kbDjDg1yIP0VKXO/9GzmOglv9ALezf8GoxgGhhzt1wI4fxMQ/DAaAWHvy2GIL8kgD0y8YbaYYP5xgkG888zFNsgU+L3O3mzR8+VNTlzruR/ODAmwo72b7j7Rtv4NMCBgkIdwIxM0H1o2AUjIJRMAoIAQDjn1B/FtjmvwAAAABJRU5ErkJggg==","orcid":"","institution":"Victoria University","correspondingAuthor":true,"prefix":"","firstName":"Abdi","middleName":"D.","lastName":"Osman","suffix":""},{"id":272542509,"identity":"abf94460-da59-4352-a7c1-544a1fee56fb","order_by":1,"name":"Daryl Yeak","email":"","orcid":"","institution":"Austin Health","correspondingAuthor":false,"prefix":"","firstName":"Daryl","middleName":"","lastName":"Yeak","suffix":""},{"id":272542510,"identity":"f8bc1347-1df2-4aeb-9ed1-49f1b7e6194e","order_by":2,"name":"Michael Ben-Meir","email":"","orcid":"","institution":"Austin Health","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Ben-Meir","suffix":""},{"id":272542511,"identity":"84d8cb55-3391-4781-982f-caf75eb7aae6","order_by":3,"name":"George Braitberg","email":"","orcid":"","institution":"Austin Health","correspondingAuthor":false,"prefix":"","firstName":"George","middleName":"","lastName":"Braitberg","suffix":""}],"badges":[],"createdAt":"2024-02-08 09:29:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3939460/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3939460/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52862850,"identity":"30559fb5-b3e4-470a-b27e-513b0c1a5862","added_by":"auto","created_at":"2024-03-18 04:52:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":288443,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3939460/v1/bd7c79e0-e6ef-4e5d-85f1-f71188c0dac0.pdf"},{"id":51126492,"identity":"3d6d6dfd-8c8a-444a-b79c-a5c9f497a64c","added_by":"auto","created_at":"2024-02-14 15:44:14","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":38550,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.Thematicanalysis.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-3939460/v1/c5c64ccd5368fff1b06f54ee.xlsx"},{"id":51126271,"identity":"65fbe6bb-ec54-43a7-b2bc-d785a27e19c1","added_by":"auto","created_at":"2024-02-14 15:36:14","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":33593,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2.Thematicanalysis.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-3939460/v1/f825a75fcbb03c13cee319c6.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Emergency department staff opinion on newly introduced phlebotomy services in the department. A cross-sectional study incorporating reflexive thematic analysis.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe demand for Emergency Department (ED) services, in terms of both patient numbers and complexity has continued to grow. In Australia there has been an increase in the ED patient presentation rate from 321 per 1000 to 339 per 1000 between 2017-18 and 2021\u0026thinsp;\u0026minus;\u0026thinsp;22\u003csup\u003e1\u003c/sup\u003e. Similar trends have been reported in other countries\u003csup\u003e\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCurrently, ED presentations have rebounded to pre-pandemic levels or higher. The underlying causes are multifactorial and encompass increased morbidity from COVID-19 and its complications, morbidity resulting from deferred care, and the progressively aging population\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe increased workload has the potential to compromise patient care\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Consequently, new models have been introduced to manage demand, mitigate risk, and improve safety. Such models include the ability of triage staff to \u0026ldquo;front load\u0026rdquo; clinical care and/or interventions\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Early point of care testing at triage has been shown to reduce ED length of stay (EDLOS)\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. However this may come at a cost as it redirects the focus of triage staff from their primary role; which is to triage patients\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Most recently, virtual care has the potential to divert patients from visiting an ED\u003csup\u003e\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe report an intervention that allows \u0026ldquo;front loading\u0026rdquo; of care to occur while not redirecting triage staff from their core role by introducing phlebotomists at triage to perform blood testing (including venous blood gas (VBG) analysis), LIAT testing for COVID-19\u003csup\u003e19\u003c/sup\u003e and ECGs as directed by triage nurses or medical staff at triage\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn early 2023, a full-time phlebotomy service with 24/7 coverage was introduced at the ED triage of our health service, a quaternary facility. To assess the impact of this role on patient care and staff satisfaction, we designed a comprehensive mixed method study. Here, we present the findings of our cross-sectional study, which is based on feedback obtained from a muti-disciplinary survey of ED staff and phlebotomists. The main aim of our study was to gather the thoughts and opinions of ED nursing staff, medical personnel, and phlebotomists regarding the role.\u003c/p\u003e"},{"header":"Method","content":"\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eWe undertook a voluntary, anonymous, cross-sectional survey at a metropolitan hospital\u0026rsquo;s ED in Melbourne from 5th October to 11th November 2023, surveying clinical healthcare personnel. The hospital is a quaternary referral facility, and the ED has a mixed (adult, paediatric) annual census of approximately 90,000 patients (about 250 per day). Ethical approval for this study was obtained from the Institution\u0026rsquo;s Human Research Ethics Committee.\u003c/p\u003e\n\u003ch2\u003eDeveloping the questionnaire\u003c/h2\u003e\n\u003cp\u003eIn the absence of a validated survey, we designed and developed a customised set of questions and tested them with a group of non-study team members, representing the specific work groups we were targeting, to ensure the questions' effectiveness and acceptability.\u003c/p\u003e\n\u003cp\u003eThe final questionnaire was divided into two sections: Part A, which encompassed seven multiple-choice questions focused on socio-demographic details; and Part B, which included seven questions focused on the role of the phlebotomist. Among these, six were multiple-choice questions, some of which involved branch logic, along with open-ended inquiries, while one was entirely open-ended. The closed format questions required an ordinal response or used a five scale Likert ranging from strongly agree to strongly disagree.\u003c/p\u003e\n\u003cp\u003eThe collected variables comprised participant information such as gender, age range, discipline or craft group, employment category (full-time/part-time/casual), experience working in triage, and the duration of practice. Inquiries regarding the phlebotomist\u0026rsquo;s role focused on awareness of the role, experience working alongside a phlebotomist, the role\u0026rsquo;s impact on expediting patient diagnosis and treatment, whether it enhanced patient safety in the waiting room, its effect on the proportion of patients who did not wait for treatment, and its influence on staff satisfaction.\u003c/p\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eRecruitment\u003c/h2\u003e\n\u003cp\u003ePurposive sampling was employed to target a cohort of 340 nurses, doctors, and phlebotomists for participation. Recruitment efforts involved project announcements through the department's weekly electronic newsletter and during staff meetings. The newsletter included a QR code and a link directing individuals to an organizational REDCap site. This site outlined the study's aims and provided instructions on accessing the survey. A plain language statement detailing the study was made available via the provided link. Upon accessing the survey site, staff members were presented with information about the study aims and asked to provide consent. Upon selecting 'yes,' participants gained access to the questionnaire.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eData collection\u003c/h2\u003e\n\u003cp\u003eData were collected for about five-week period, from 5th October to 11th November 2023, using online electronic data capture tool (REDCap) hosted by Austin Health. Invitation to participate was sent through the department\u0026rsquo;s electronic newsletter with a QR code and a link to the survey on the 5th of October 2023, followed by weekly reminders in the newsletter.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eThe questionnaire responses were exported to STATA 18e statistical software\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e for analysis. Following exportation to STATA, the open-ended responses were retrieved from the software\u0026rsquo;s data editor and transcribed into a Microsoft\u003csup\u003eR\u003c/sup\u003e office 365 Excel spreadsheet. Using a reflexive thematic analysis approach\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, after familiarization with the data, each response was coded into a theme. Upon completion of coding by AO, GB and DY convened to review and discuss each theme considering the related quote. In cases where there were discrepancies in codes/themes, the group reached a consensus on which themes to include considering the study aim.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistics\u003c/h2\u003e\n\u003cp\u003eWe did not perform a priori sample size calculation since our approach involved purposive sampling, aiming to recruit as many staff members as possible. The favorable response received (~\u0026thinsp;61%, n\u0026thinsp;=\u0026thinsp;207) ensured a study power of over 80%, obviating the need for a post-hoc power calculation.\u003c/p\u003e\n\u003cp\u003eNumerical data are presented as counts and percentages accompanied by 95% confidence intervals (95% CI). In instances of missing values, data are denoted as n (number of cases)/N (total number of instances where the value was known), without making assumptions about the missing data.\u003c/p\u003e\n\u003cp\u003eFor non-normally distributed data, differences were assessed using either the one-way ANOVA or two-sample t test, while categorical data differences were evaluated using the Chi-square or Fisher\u0026rsquo;s exact test, as appropriate. Where there was a need to cross-reference categorical and numerical data, regression tests were used. A two-sided level of significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Information\u003c/h2\u003e \u003cp\u003eThe response rate for the questionnaire was 61% (n\u0026thinsp;=\u0026thinsp;207) with participant characteristics shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Staff responses to the questionnaire were one-sided, hence the p value.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStaff demographic and measure of association with phlebotomist services on diagnosis and treatment.\u003c/span\u003e (Pearson/Fisher\u0026rsquo;s exact) n\u0026thinsp;=\u0026thinsp;207.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value (CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e162 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.625\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (19%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrefer not to say\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026thinsp;\u0026le;\u0026thinsp;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.393\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u0026thinsp;\u0026le;\u0026thinsp;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u0026thinsp;\u0026le;\u0026thinsp;45 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (19%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u0026thinsp;\u0026le;\u0026thinsp;55 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (12%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;55 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDiscipline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e151 (73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.823\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47(23%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhlebotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eWork category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.944\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePart time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e151 (73%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCasual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBank\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you work in\u003c/p\u003e \u003cp\u003eTriage?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117 (57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.389\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eYears of practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.715\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eYears of practice at Austin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.415\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePhlebotomists\u0026rsquo; role\u003c/h2\u003e \u003cp\u003eNearly all the staff (99.5%) reported being aware of the presence of phlebotomists in the ED, while only 57% of the staff reported working in triage (p\u0026thinsp;=\u0026thinsp;0.048, 0.0001599 to 0.043073). As triage is a specialised area, only suitably trained ED nurses with post-graduate qualifications are able to work at triage and only consultant doctors are able to undertake the \u0026ldquo;doctor at triage\u0026rdquo; role known as Multi-Disciplinary Triage (MDT) in our department\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. However, the high staff awareness attests to the role's impact beyond triage.\u003c/p\u003e \u003cp\u003eWhen surveyed about their perception of the phlebotomist role at triage, most staff (97%) reported finding them to be very supportive, with no differences observed across staff employment categories (p\u0026thinsp;=\u0026thinsp;0.423), disciplines (p\u0026thinsp;=\u0026thinsp;0.316), gender (p\u0026thinsp;=\u0026thinsp;0.614) or years of service (p\u0026thinsp;=\u0026thinsp;0.122). When asked about the contribution of phlebotomists to improving patient safety, 99.5% of the staff agreed, irrespective of staff discipline (p\u0026thinsp;=\u0026thinsp;0.066), age groups (p\u0026thinsp;=\u0026thinsp;0.390) or employment category (p\u0026thinsp;=\u0026thinsp;0.702)\u003c/p\u003e \u003cp\u003eStaff members across all disciplines demonstrated a positive response when asked about their belief in the impact of the phlebotomist's role on expediting patients' diagnosis and treatment (99.5%), enhancing patient safety (99.5%), and reducing instances of patients not waiting for treatment (95%). Furthermore, all responded positively to improvement in staff satisfaction.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eThematic analysis of open-ended question.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eIn response to the impact of phlebotomists at triage on staff satisfaction, staff were prompted with an open-ended question to express their views on whether they believed this role enhanced or did not enhance staff satisfaction. The response to the question regarding the impact of phlebotomists on staff satisfaction yielded a unanimous result, with 100% (n\u0026thinsp;=\u0026thinsp;195) of the participants responding with a \u0026lsquo;yes\u0026rsquo;. Participants were able to explain the reasoning behind their response in the open-ended question that followed, from which the following five themes emerged (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Among the 195 responses,184 were completed responses available for coding and analysed thematically (supplementary file 1).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ereflexive thematic analysis with frequencies of the themes and selected quotes (n\u0026thinsp;=\u0026thinsp;184)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency of theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelected quote related code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelected quote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriage specific role focus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;1. valuable resource, takes a huge burden off triage and let's triage be able to focus on the patients needs and reassessments. 2. running LIATs and having to wait for the machine to be free, I can be off the floor for 15/20 mins waiting for a machine. which is time I can be used elsewhere. that puts a huge burden on the triage staff whilst I've stepped away. 3. I've definitely stopped ordering bloods and ecg for pts because I know I'll never get to them anytime soon. unless they're a good sounding cardiac chest pain. if you're taking away our resources, why should triage have to work harder to fill the gap.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpedite treatment decision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Having phlebotomists 24 hours in ED is an amazingly helpful resource. When ED is extremely busy having bloods done allows a baseline to be established before the patient even reaches the cubicle. Sometimes this even allows patients to go home when they are seen by the MDT and frees up a cubicle. Phlebotomists help with patient flow, they start point of care early so therefore a patient breaching in ED is less likely. We need phlebotomists 24/7 in Emergency.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSafety filter against missed opportunities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Respectfully, this is the most perplexing and clearly money driven decision the upper management of this department have ever made. Yet again, another example of asking your staff to do more with less. If you've ever wondered why retention of Critical Care Trained staff is so poor, here is a prime example of why. Triage is the most dangerous and mentally taxing area of the entire department. It is easier to be in charge of the department than it is working at triage, I have ample experience in both. The phlebotomists have been such a valued and integral member of the triage team, and I have no doubt they have saved countless lives because we were able to identify gravely abnormal blood results or ECGs because of their timely and efficient work. They are extremely hard working, always take direction from triage staff and are just very, very good at their role. You simply cannot ask triage nurses who are already struggling to make it through a line that streams out the door and dealing with the cognitive load of unwell patients deteriorating in the WR, to take more onto their already extremely stressful and resource intensive workload. Patients will sit in that waiting room, with high lactates or high troponins to know ones knowledge because they haven't been tested for them. More patients will die. There will be more delays to treatment, department flow will falter and ultimately, you will lose more senior, experienced, highly skilled staff because of this financially driven decision.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;- patients more satisfied as they are receiving investigations earlier, and by the time they receive a cubicle or are seen by a clinician they have results available that we can either act upon or discharge them home - patients are therefore more satisfied and less likely to discharge AMA or express anger towards staff - patients grateful that they are being checked up on while they wait - staff are able to then re prioritise patients based on pathology results and act upon these results while the patient awaits a cubicle, as well as detect deterioration earlier, leading to more staff job satisfaction - staff inside the department have more time to then complete additional investigations or assessments once the patient arrives to them.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncreased staff satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIS023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Having the phelbotomists work in triage has been one of the best changes within the ED since I started here in 2019. They work incredibly hard, they are very efficient and able to complete the bloods/ECGs and LIATs for WR patients much more efficiently and quickly than any nursing staff can. They have boosted the morale of the triage nurses working out there as it takes the stress and worry away from not being able to accomplish said tasks, as more often than not we have a line of patients waiting to be triaged throughout every shift. There has definitely been a huge increase in staff satisfaction and reduction of burn out (personally as well as talking to other nursing staff) since they have been working with us. I am extremely disappointed and concerned for patient safety that they have now only staffed the PM shift.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn a separate open-ended question, the staff were given the opportunity to share additional thoughts or opinions regarding the phlebotomist\u0026rsquo;s role, specifically in obtaining regular blood tests, blood gases, LIAT for COVID-19 and ECG in triage. Their responses are summarised in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, with detailed results available in supplementary file 2. Several themes were found to be similar or closely related to those discussed in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ereflexive thematic analysis with frequencies of the themes and selected quotes (n\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency of theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelected quote related code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelected quote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriage specific role focus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Out of all of the areas in ED, triage is where staff feel the most resource poor, and this translates to feelings of stress, frustration and of being overwhelmed. Having 20 people in the waiting room on average (I know it gets lower/higher than this), while staring down a line of people who are in pain, frustrated and unwell waiting to be triaged, the last thing you want to have to do is stop triaging and take 5\u0026ndash;10 minutes in order to get the ECG and bloods on the convincing cardiac chest pain you've got in front of you. I can understand that at times the people giving out the funding are most likely to visit are when it is seemingly 'quiet' in the WR, but as someone who has worked in many senior roles, I can honestly say there isn't a harder job in the department than being the MDT or nursing staff working out there. Taking away the phlebotomists will be the straw that breaks a few of these tired, frustrated camels backs. IF the hospital cares about Safewards, KPIs or perhaps even their tired staff during this time, I would strongly suggest NOT taking away one of the very few things that makes the front door of our hospital a workable environment.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupport beyond triage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\"Having phlebotomists are so important in emergency as when patients come into the cubicles their care has already been started. This is evident if a patient has chest pain and waits in the WR for long periods. When the phlebotomist worked the important blood tests were done\u0026thinsp;+\u0026thinsp;we are able to gather an idea of the severity.\"\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatience/waiting for treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\"The phlebotomists have made a world of change in triage for both the staff and the patients. I have found working in triage less stressful and more streamlined for both staff and patients. I am relieved knowing the patients are getting the tests, procedures and treatment they so desperately need in a timely manner. It is also a weight of my shoulders knowing I am supported as a staff member to provide the best care I can. I also realise the impact it has on the patient's family to know the treatment is being started in the waiting room, and that time spent waiting is not a waste. Please bring back this role on a permanent basis. All the phlebotomists who worked in triage have been lovely to work with and professional in all capacities.\"\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk mitigation/care escalation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eR011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\"I think the removal of 24hr phlebotomists was a very poor decision and has absolutely no benefit. The outcome of removing this vital role will be poor patient\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eoutcomes, including increased agitation and frustration due to longer wait times, and possibly death due to the delay in treatment. This also puts unnecessary pressure on us nurses who are already working under the pump to just be able to perform our regular duties, which will increase stress and burn out. We need our 24 hour phlebotomists in order to effectively care for patients within a timely manner - it shouldn't have to take a patient death for this to be realised.\"\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValuable/vital resource\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eV004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\"We need them to become a permanent part of the ED team with fixed EFT, covering all shifts. Early ECG's help mitigate risk factors, allow for downgrading triage categories, or escalating pt care LIAT\u0026rsquo;s- help us understand cause of symptoms and where to place patients VBG's- allow for immediate results, again escalating care as needed\"\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe implementation of a phlebotomy service in the ED has not been extensively studied on a large scale, leading to limited availability of literature on this subject. The few centers who have implemented such services over the past decade have reported mixed results\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. We undertook this study to gather staff opinion and thoughts on the phlebotomist\u0026rsquo;s role in the department. A quantitative observational study of the trial is reported elsewhere.\u003c/p\u003e \u003cp\u003eOur staff overwhelmingly expressed appreciation for and support of retaining phlebotomy services within the department. The recruitment and retention of nursing staff in the Emergency Department (ED) have been recognized as a global challenge. According to a study by Cornish\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, 48.2% of nursing respondents indicated their intention to leave emergency nursing within 5 years.\u003c/p\u003e \u003cp\u003eThis endorsement from our staff reflects the additional stress placed on triage, especially considering the challenges in recruiting, and retaining experienced staff post-pandemic. Such challenges were noted in some of the free-text comments, exacerbating stressors at triage,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWith such a junior cohort of staff triage is very stressful. Having a phlebotomist allows triage staff to recheck obs, and attend to the usually chaotic WR, taking some of the burden off triage staff\u0026rdquo;.\u003c/em\u003e (IS001)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn response to this staffing challenge, it is anticipated that EDs will explore additional support services beyond the traditional nursing and medical workforce. Some have introduced paramedics, while others have employed other technicians in the ED\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. We believe that phlebotomists should be considered an integral part of the new ED staffing workforce matrix.\u003c/p\u003e \u003cp\u003eStaff reflected the additional stress this placed on triage by stating,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eBecause pathology results are returned earlier identifying potentially life-threatening conditions. Triage is already an enormously stressful area to work and having 40\u0026thinsp;+\u0026thinsp;patients with unknown clinical conditions only adds to the stress of staff. Trying to find time to do path on patients you are concerned about whilst also navigating an endless stream of new patients to triage is near impossible. Having the pathology staff has decreased the anxiety levels of staff working at triage\u003c/em\u003e\u0026rdquo;. (S005)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDespite only 57% of our study participants directly working in triage, the phlebotomists\u0026rsquo; roles had a far-reaching impact across the entire department. This is evidenced by the overwhelming positive response regarding the substantial impact they have made in the department. Staff acknowledged the phlebotomists\u0026rsquo; contribution beyond triage (S014, Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) and recognition of their value in the department with one participant stating,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"The are absolutely ESSENTIAL to the workings of this department. The have a huge impact on flow as results are back before the patients even hit the cubicles in most cases and plans can immediately be put into place re disposition. There are zero negatives having phlebotomists working at triage 24/7\u0026rdquo;.\u003c/em\u003e (V006)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe themes presented in Tables \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e broadly captured the elements which are essential for staff and patients\u0026rsquo; satisfaction and wellbeing.\u003c/p\u003e \u003cp\u003eThe theme \u0026ldquo;triage specific role focus\u0026rdquo; highlighted the liberation of triage staff from additional obligations, enabling them to concentrate solely on the task of triaging as mentioned by T015,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;- supports triage nurses to continue triaging instead of attending to path/ECGs which can delay treatment/getting through triage line\u0026rdquo;.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe staff have repeatedly mentioned triage should be for triaging patients only as they shared their concerns on the unstable patients in the long triage cues\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe themes \u0026ldquo;expedite treatment decision\u0026rdquo; and \u0026ldquo;support beyond triage\u0026rdquo; emphasises the importance of prompt initiation of investigations. Patients frequently experience prolonged waiting periods in the waiting room. By commencing these investigations early, waiting time for results is reduced. This ensures that when patients are due to be seen, the results are more readily available for informed decision-making and treatment planning. This enhances both provider and patient satisfaction and reduces the proportion of those who opt not to wait for treatment\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. The themes on \u0026ldquo;safety filter against missed opportunities\u0026rdquo; and \u0026ldquo;risk mitigation/care escalation\u0026rdquo; builds upon expediting treatment decision, a core component of which is availability of investigations that may identify undetected critical conditions. Following the introduction of venous blood gas analysis by the phlebotomists we identified 18 episodes where conditions such as electrolyte disturbances were identified early leading to a clinically significant change in care. This has been identified previously\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Patient satisfaction\u0026rdquo; and patience/waiting for treatment\u0026rdquo; themes focus on an important person-centered outcome indicator. These themes emerged as all-encompassing with various elements contributing to patient contentment mentioned. With long waiting time in ED waiting rooms, initiating investigations early by the phlebotomists under supervision of the triage nurses is believed to be reassuring for patients, leading to a reduction in patient enquiries at the triage window. This proactive approach reduces patient\u0026rsquo;s aggression towards staff due to lengthy waits and positively impacts patients\u0026rsquo; decision to wait for treatment rather than also leaving due to prolonged waiting times\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Overall, it contributes to a more positive patient experience in the waiting room.\u003c/p\u003e \u003cp\u003eThe themes \u0026ldquo;increased staff satisfaction\u0026rdquo; and \u0026ldquo;valuable/vital resources\u0026rdquo; elaborates on how the activities of the phlebotomist contribute to enhancing staff morale at triage and beyond. Staff members working in the emergency cubicles expressed considerable appreciation for receiving patients who have already undergone preliminary investigations. This situation expedites patient treatment and streamlines the flow of patients through the system, positively impacting overall staff satisfaction. The recognition of this support in expediting patient care in triage and beyond contributes significantly to staff morale and satisfaction\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study has the following limitations: Firstly, the absence of a pre-validated survey tool meeting our specific objectives necessitated the creation of an individual survey tool for a singular time-point use. Secondly, the study was conducted at a single site, potentially restricting its external validity. Thirdly, While the overwhelmingly positive results in some instances may suggest a biased sample, the large response rate (61%) would mitigate against this.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEmergency Departments continue to seek new models of care to deal with increasing demand. We present a model that utilises an existing workforce, reallocated them from the ambulatory and outpatient setting to the ED and increasing their scope to complement triage needs, namely COVID-19 PCR testing, ECG and venous blood gas analysis.\u003c/p\u003e \u003cp\u003eOur staff have identified these tasks, and the concierge impact of the phlebotomists as a role that enhances patient care and safety. Specifically, alleviating triage staff from additional responsibilities associated with providing patient care in the waiting room, holds the promise of enhancing triage services to patients, improving both pace and accuracy of triaging. Staff expressed satisfaction that patient care now begins in the waiting room, particularly after extended waiting periods and before bed allocation. This improvement, they believe contributes to timely treatment and disposition decisions, and increased patient satisfaction.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eED- Emergency Department\u003c/p\u003e\n\u003cp\u003eEDLOS- Emergency Department Length of Stay\u003c/p\u003e\n\u003cp\u003eECG- Electro Cardiography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate \u0026ndash; Ethics approval was obtained from the Organizational Human Research Ethics Committee reference HREC/101323/Austin-2023. Consent was obtained from the participants. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eConsent for publication - Both ethics and participants were informed of the intention to publish.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials \u0026ndash; Data submitted as supplementary files. Questionnaire can be shared from REDCap data dictionary where reasonable request is submitted.\u003c/p\u003e\n\u003cp\u003eCompeting interests \u0026ndash; No competing interest to declare.\u003c/p\u003e\n\u003cp\u003eFunding \u0026ndash; The study did not receive any funding at any stage.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions \u0026ndash; All authors have equally contributed.\u003c/p\u003e\n\u003cp\u003eAcknowledgements - We acknowledge the participants of this survey who, despite their usually busy work, found the time to provide responses to our questionnaire. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare. Emergency department care activity. . 2023. https://www.aihw.gov.au/reports-data/myhospitals/intersection/activity/ed#:~:text=Over%20time%2C%20the%20number%20of,339%20presentations%20in%202021%E2%80%9322.\u003c/li\u003e\n\u003cli\u003eAboagye-Sarfo P, Mai Q, Sanfilippo FM, Preen DB, Stewart LM, Fatovich DM. Growth in Western Australian emergency department demand during 2007\u0026ndash;2013 is due to people with urgent and complex care needs. \u003cem\u003eEmergency Medicine Australasia\u003c/em\u003e. 2015;27(3):202-209. doi:https://doi.org/10.1111/1742-6723.12396\u003c/li\u003e\n\u003cli\u003eDel Mar P, Kim MJ, Brown NJ, Park JM, Chu K, Burke J. Impact of COVID-19 pandemic on emergency department patient volume and flow: Two countries, two hospitals. \u003cem\u003eEmergency Medicine Australasia\u003c/em\u003e. 2023;35(1):97-104. doi:https://doi.org/10.1111/1742-6723.14077\u003c/li\u003e\n\u003cli\u003eRebecca Leigh J, Bramston C, Beauchamp A, et al. Impact of COVID-19 on emergency department attendance in an Australia hospital: a parallel convergent mixed methods study. \u003cem\u003eBMJ Open\u003c/em\u003e. 2021;11(12):e049222. doi:10.1136/bmjopen-2021-049222\u003c/li\u003e\n\u003cli\u003eSkinner HG, Blanchard J, Elixhauser A. \u003cem\u003eTrends in Emergency Department Visits, 2006\u0026ndash;2011\u003c/em\u003e. Agency for Healthcare Research and Quality (US), Rockville (MD); 2006.\u003c/li\u003e\n\u003cli\u003eTang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and Characteristics of US Emergency Department Visits, 1997-2007. \u003cem\u003eJAMA\u003c/em\u003e. 2010;304(6):664-670. doi:10.1001/jama.2010.1112\u003c/li\u003e\n\u003cli\u003eBurkett E, Martin-Khan MG, Scott J, Samanta M, Gray LC. Trends and predicted trends in presentations of older people to Australian emergency departments: effects of demand growth, population aging and climate change. \u003cem\u003eAust Health Rev\u003c/em\u003e. Jul 2017;41(3):246-253. doi:10.1071/ah15165\u003c/li\u003e\n\u003cli\u003eLeonard C, Bein KJ, Latt M, Muscatello D, Veillard A-S, Dinh MM. Demand for emergency department services in the elderly: An 11 year analysis of the Greater Sydney Area. \u003cem\u003eEmergency Medicine Australasia\u003c/em\u003e. 2014;26(4):356-360. doi:https://doi.org/10.1111/1742-6723.12250\u003c/li\u003e\n\u003cli\u003eGorski JK, Batt RJ, Otles E, Shah MN, Hamedani AG, Patterson BW. The Impact of Emergency Department Census on the Decision to Admit. \u003cem\u003eAcademic Emergency Medicine\u003c/em\u003e. 2017;24(1):13-21. doi:https://doi.org/10.1111/acem.13103\u003c/li\u003e\n\u003cli\u003eMatthias W, Andreas M, Stephan H, Susanne W, Maria W. Work conditions, mental workload and patient care quality: a multisource study in the emergency department. \u003cem\u003eBMJ Quality \u0026amp;amp;amp; Safety\u003c/em\u003e. 2016;25(7):499. doi:10.1136/bmjqs-2014-003744\u003c/li\u003e\n\u003cli\u003eWolf LA, Delao AM, Perhats C, Moon MD, Zavotsky KE. Triaging the Emergency Department, Not the Patient: United States Emergency Nurses\u0026rsquo; Experience of the Triage Process. \u003cem\u003eJournal of Emergency Nursing\u003c/em\u003e. 2018/05/01/ 2018;44(3):258-266. doi:https://doi.org/10.1016/j.jen.2017.06.010\u003c/li\u003e\n\u003cli\u003eRichardson JR, Braitberg G, Yeoh MJ. Multidisciplinary assessment at triage: a new way forward. \u003cem\u003eEmerg Med Australas\u003c/em\u003e. Feb 2004;16(1):41-6. doi:10.1111/j.1742-6723.2004.00541.x\u003c/li\u003e\n\u003cli\u003eSinger AJ, Taylor M, LeBlanc D, Meyers K, Perez K, Thode HC, Jr., Pines JM. Early Point-of-Care Testing at Triage Reduces Care Time in Stable Adult Emergency Department Patients. \u003cem\u003eJ Emerg Med\u003c/em\u003e. Aug 2018;55(2):172-178. doi:10.1016/j.jemermed.2018.04.061\u003c/li\u003e\n\u003cli\u003eFekonja Z, Kmetec S, Fekonja U, Mlinar Reljić N, Pajnkihar M, Strnad M. Factors contributing to patient safety during triage process in the emergency department: A systematic review. \u003cem\u003eJournal of Clinical Nursing\u003c/em\u003e. 2023;32(17-18):5461-5477. doi:https://doi.org/10.1111/jocn.16622\u003c/li\u003e\n\u003cli\u003eVan Der Linden MC, Van Loon-Van Gaalen M, Richards JR, Van Woerden G, Van Der Linden N. Effects of process changes on emergency department crowding in a changing world: an interrupted time-series analysis. \u003cem\u003eInternational Journal of Emergency Medicine\u003c/em\u003e. 2023/02/15 2023;16(1):6. doi:10.1186/s12245-023-00479-z\u003c/li\u003e\n\u003cli\u003eJoseph MJ, Summerscales M, Yogesan S, Bell A, Genevieve M, Kanagasingam Y. The use of kiosks to improve triage efficiency in the emergency department. \u003cem\u003enpj Digital Medicine\u003c/em\u003e. 2023/02/03 2023;6(1):19. doi:10.1038/s41746-023-00758-2\u003c/li\u003e\n\u003cli\u003eMetro South Health. \u003cem\u003ePhlebotomists assisting patients at QEII ED\u003c/em\u003e. 2019. https://metrosouth.health.qld.gov.au/news/phlebotomists-assisting-patients-at-qeii-ed\u003c/li\u003e\n\u003cli\u003eStowell JR, Pugsley P, Jordan H, Akhter M. Impact of Emergency Department Phlebotomists on Left-Before-Treatment-Completion Rates. \u003cem\u003eWest J Emerg Med\u003c/em\u003e. Jul 2019;20(4):681-687. doi:10.5811/westjem.2019.5.41736\u003c/li\u003e\n\u003cli\u003eHansen G, Marino J, Wang ZX, et al. Clinical Performance of the Point-of-Care cobas Liat for Detection of SARS-CoV-2 in 20 Minutes: a Multicenter Study. \u003cem\u003eJ Clin Microbiol\u003c/em\u003e. Jan 21 2021;59(2)doi:10.1128/jcm.02811-20\u003c/li\u003e\n\u003cli\u003eStataCorp. Stata Statistical Software:Release 18. College Station, TX: StataCorp LLC. 2023;\u003c/li\u003e\n\u003cli\u003eByrne D. A worked example of Braun and Clarke\u0026rsquo;s approach to reflexive thematic analysis. \u003cem\u003eQuality \u0026amp; Quantity\u003c/em\u003e. 2022/06/01 2022;56(3):1391-1412. doi:10.1007/s11135-021-01182-y\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. One size fits all? 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The emergency nurse responses to triage interruptions and how these responses are perceived by patients: An observational, prospective study. \u003cem\u003eInternational Emergency Nursing\u003c/em\u003e. 2023/03/01/ 2023;67:101251. doi:https://doi.org/10.1016/j.ienj.2022.101251\u003c/li\u003e\n\u003cli\u003eFaber J, Coomes J, Reinemann M, Carlson JN. Creating a Rapid Assessment Zone with Limited Emergency Department Capacity Decreases Patients Leaving Without Being Seen: A Quality Improvement Initiative. \u003cem\u003eJournal of Emergency Nursing\u003c/em\u003e. 2023/01/01/ 2023;49(1):86-98. doi:https://doi.org/10.1016/j.jen.2022.10.002\u003c/li\u003e\n\u003cli\u003eBaugh CW, Freund Y, Steg PG, Body R, Maron DJ, Yiadom MYAB. Strategies to mitigate emergency department crowding and its impact on cardiovascular patients. \u003cem\u003eEuropean Heart Journal Acute Cardiovascular Care\u003c/em\u003e. 2023;12(9):633-643. doi:10.1093/ehjacc/zuad049\u003c/li\u003e\n\u003cli\u003eRobinson S. Maintaining a safe environment in emergency department waiting rooms. \u003cem\u003eEmerg Nurse\u003c/em\u003e. Dec 19 2023;doi:10.7748/en.2023.e2189\u003c/li\u003e\n\u003cli\u003eHwang S, Shin S. Factors affecting triage competence among emergency room nurses: A cross-sectional study. \u003cem\u003eJournal of Clinical Nursing\u003c/em\u003e. 2023;32(13-14):3589-3598. doi:https://doi.org/10.1111/jocn.16441\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Phlebotomist, Emergency Department, Triage, Staff, staff satisfaction","lastPublishedDoi":"10.21203/rs.3.rs-3939460/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3939460/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eThe demand for Emergency Department (ED) services, both in terms of patient numbers and complexity has risen over the past decades. According to reports, there has been an increase in the ED patient presentation rate from 321 per 1000 to 339 per 1000 between 2017-18 and 2021-22. Consequently, new care models have been introduced to address this surge in demand, mitigate associated risks, and improve overall safety. Among these models is the concept of \"front loading\" clinical care, involving the initiation of interventions at the point of arrival. This study evaluates the impact of introducing phlebotomists at triage.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eWe conducted a cross-sectional survey using purposive sampling and employed quantitative analysis, complemented by reflexive thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe response rate for the questionnaire was 61% (n\u0026thinsp;=\u0026thinsp;207) with good representation from all ED craft groups. Nearly all the staff (99.5%) reported being aware of the presence of phlebotomists in the ED, while only 57% of the staff reported working in triage (p\u0026thinsp;=\u0026thinsp;0.048, 0.0001599 to 0.043073). \u0026lsquo;Valuable/vital resource\u0026rsquo; featured as a common response. Early decision making, patient safety, staff and patient satisfaction emerged as consistent themes.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eEmergency Departments continue to introduce new models of care to address increasing demand for services. We present a model that utilises an existing workforce, relocating them from the ambulatory and outpatient setting to the ED and increasing their scope to complement triage needs, including COVID-19 PCR testing, ECG and venous blood gas analysis. Our staff have identified these tasks, and the concierge role provided by the phlebotomists as contributions to enhanced patient care and safety.\u003c/p\u003e","manuscriptTitle":"Emergency department staff opinion on newly introduced phlebotomy services in the department. A cross-sectional study incorporating reflexive thematic analysis.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-14 15:36:09","doi":"10.21203/rs.3.rs-3939460/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f94dc478-5357-4015-b8e4-8382cad24b60","owner":[],"postedDate":"February 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-18T04:44:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-14 15:36:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3939460","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3939460","identity":"rs-3939460","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}