Date of Award

January 2022

Document Type

Open Access Thesis

Degree Name

Doctor of Nursing Practice (DNP)


Yale University School of Nursing

First Advisor

Laura Andrews


Inappropriate attendance in US emergency departments (ED) account for up to 40% of all ED visits. Overcrowding can lead to poorer outcomes for patients in the ED, including a higher rate of triage to non-monitored area and longer timeframes to physician initial assessment. Additionally, the cost for unnecessary ED care is two to three times greater than care is in an Urgent Care or Clinic and cost billions of dollars in the U.S. yearly. Licensed Independent Providers (LIP); Medical Doctors and Nurse Practitioners were embedded into a VHA VISN registered nurse telephone triage system. Protocols were developed for additional opportunities for assessment and patient health concern resolution of calls by the LIP. These calls included those already determined to require ED disposition by the RN protocols. Calls were tracked for 3 months. There were 1608 calls sent from RN to LIP staff. Of these, 104 were initially designated as ED dispositions. After the LIP intervention, 55 calls, 53%, were resolved and the patient no longer given an ED disposition. Patient satisfaction was also reviewed via Press Ganey and there overall was no difference in patient satisfaction for the 2 quarters before the intervention and the quarter that included the intervention. The percentage of calls sent from RN to the LIP that involved initial ED dispositions was only 7% of the total calls, RN staff outnumbered LIP 7 to 1 and RNs covered 24 hours a day, while LIP staff 12 hours a day. These represent opportunities for future exploration and expansion. Scalability is available through the VHA, the largest healthcare organization is the US and its nationwide telephone triage network and national level program managers.


This is an Open Access Thesis.

Open Access

This Article is Open Access