Does a novel digital self-triage and scheduling pathway reduce wait times for low-acuity emergency department visits in a Canadian community hospital? A prospective cohort study

Abstract

Objectives

The objectives were to evaluate if a novel self-triaging and self-scheduling emergency department (ED) service, the Minor Ailment Patient Pathway (MAPP), can safely reduce ED wait times for low-acuity patients presenting with either cold and influenza or musculoskeletal ailments.

Design

Prospective cohort study including all consecutive ED patients from 1 June 2023 to 31 March 2024. Outcomes for MAPP patients were compared with contemporaneous, matched ED patients who followed the usual care (UC) ED intake and evaluation process.

Setting

Single acute care hospital, Royal Victoria Regional Health Centre, located in Ontario, Canada.

Participants

Of 73 132 ED visits during the study period, 2766 (3.8%) used the MAPP. Low-acuity patients, defined by the Canadian Triage and Acuity Scale (CTAS) 3 or 4–5, comprised 59.4% and 34.1%, respectively, of all ED patients.

Results

Most MAPP visits were for cold and influenza symptoms (63.6%) or musculoskeletal ailments (18.4%). Compared with CTAS-matched UC patients, MAPP users had a shorter mean length of stay (LOS) and faster mean physician initial assessment (PIA) time (adjusted LOS: −0.44 hours, 95% CI −0.84 to −0.05 and adjusted PIA: −1.22 hours, 95% CI −1.42 to −1.01). 7-day return visits occurred in 3.2% of MAPP patients compared with 4.4% of UC patients (p=0.002), with fewer admissions on return (1.8% vs 13.2%; p<0.001). Over 95% of surveyed patients reported being satisfied or very satisfied with the MAPP process and their overall ED experience.

Conclusions

MAPP was associated with shorter LOS, faster PIA, lower rates of return visits and hospital admissions, and high patient satisfaction, all suggestive of a safe, efficient and patient-centred ED service. Despite these benefits, MAPP was underused with only 9.3% of all cold and influenza and musculoskeletal ED patients self-triaging and self-scheduling an ED MAPP visit during this cohort period.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The Minor Ailment Patient Pathway (MAPP) uses a low-tech approach to internally divert low-acuity patients from the main emergency department (ED) that can be easily scaled up and implemented in other EDs.

• By permitting patients to self-schedule ED visits during periods of low ED patient volumes, hospitals can exert greater control of the flow of all ED patients to optimise resource use.

• As with other healthcare innovations that require digital and health literacy, a significant proportion of the population may be inadvertently excluded from participation.

• This was a single-site observational study, so MAPP needs to be scaled up and implemented in other ED sites to externally validate its observed benefits.

• In Canada, self-scheduling an ED arrival time may violate the current reimbursement policies for ED visits, perhaps even making these visits ineligible for remuneration.

Background

Emergency departments (EDs) are critical access points for unscheduled acute care and often function as safety nets for patients facing barriers elsewhere in the health system.¹ However, limited access to primary care, seasonal surges in illness and persistent staffing shortages have contributed to overcrowding.^{1 2} These pressures result in prolonged wait times, delayed assessments and poorer clinical outcomes.³,⁵

Low-acuity, non-admitted (LANA) patients represent a substantial portion (~23%) of ED visits in Ontario.⁶ These individuals are typically triaged as Canadian Triage and Acuity Scale (CTAS) level 4 or 5, though some receive a CTAS 3 Score. They frequently present with minor injuries or respiratory symptoms and may face long waits, even when presenting with concerns that are generally straightforward to assess and manage. The drivers of these visits are multifactorial, including difficulty accessing timely primary care, limited system navigation tools and the appeal of 24/7 access to diagnostics and treatment.⁷,¹⁰

To manage this demand, EDs have introduced operational models such as fast-track zones, rapid medical evaluation units and community redirection programmes.¹¹,¹³ In parallel, digital health innovations, such as symptom checkers, asynchronous scheduling tools and virtual triage platforms, have emerged to support decision-making and care navigation.¹⁴,¹⁶ However, these technologies have primarily focused on diverting patients away from EDs, with less emphasis on supporting care for those already intending to visit the ED.

This study evaluates a novel ED process we have termed the Minor Ailment Patient Pathway (MAPP), which integrates self-triage and self-scheduling to enable same-day or next-day ED care for low-acuity concerns. By aligning the cadence of low-acuity arrivals with staffing capacity and clinical readiness, we hypothesised that MAPP would be associated with shorter length of stay (LOS) and faster time to physician initial assessment (PIA) compared with usual care (UC), while maintaining patient safety and achieving high levels of satisfaction.

Methods

Study design and setting

This single-centre, prospective, comparative-effectiveness cohort study was conducted at Royal Victoria Regional Health Centre (RVH), a 450-bed tertiary care hospital located in Barrie, Ontario. This study followed Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines for observational cohort studies (online supplemental section 1.0).¹⁷ In 2022, RVH’s ED managed 80 662 visits, averaging 261 visits and 33 admissions per day. The ED includes 48 stretcher locations and 15 treatment chairs. From 2015 to 2023, the average LOS for LANA patients was 5.9 hours (95% CI 5.7 to 6.2), approximately 1.05 hours (95% CI 0.63 to 1.45) longer than the provincial average.

Study phases

The study was conducted in two phases. Phase I (01 June 2023 to 31 August 2023) evaluated the feasibility and safety of MAPP for patients with musculoskeletal complaints. Six weekday arrival time slots were made available and eligible patients were seen in the main ED. After more than 100 patients were assessed without safety concerns, phase II (01 September 2023 to 31 March 2024) introduced a dedicated care area adjacent to the ED, called the ‘Pink Zone’ and expanded eligibility to include patients with cold and influenza symptoms. Daily arrival time slots increased to 40. The Pink Zone had four stretcher spaces and was staffed by a dedicated clerk, registered nurse and a rotating team of physician assistants and ED physicians. The study end date was determined by ED leadership once operational testing was complete.

MAPP design

The study team developed MAPP to support patient self-triage using a structured sequence of screening questions and eligibility rules (online supplemental section 2.0). The tool targeted patients with CTAS scores of 4 or 5 and presenting complaints consistent with musculoskeletal injury or cold and influenza symptoms.

Screening questions

The self-screening questionnaire was developed by a multidisciplinary group of emergency physicians and operational leaders using consensus-based inclusion and exclusion criteria. The questionnaire underwent iterative refinement and expert review prior to implementation to ensure face and content validity; however, formal psychometric validation was not performed.

Patients accessed MAPP through a publicly accessible online link and were able to self-schedule a same-day or next-day ED arrival time. Eligible patients were selected from 15-minute time slots offered Monday to Friday between 09:00 and 16:40, hours historically associated with lower ED volumes. Booking eligibility was determined in real time by embedded screening logic, with slots assigned on a first-come, first-served basis. Community social media channels and radio broadcasting were used to raise awareness of the tool as a resource for timely evaluation and treatment of minor ailments.

Following self-triage and self-scheduling, patients entered identifying information via a secure, Personal Health Information Protection Act (PHIPA)-compliant Research Electronic Database Capture System (REDCap) interface (https://projectredcap.org/resources/citations/) hosted on RVH servers. Confirmation emails were sent automatically. Real-time scheduling data were made available to ED staff via a secure calendar interface displaying patient name, arrival time and reason for visit.

On arrival, MAPP patients completed registration and triage in the main ED in phase I. In phase II, patients were instructed to present directly to the Pink Zone location for registration and triage. In contrast, UC patients underwent registration and triage through the standard workflows in the main ED. Clinical care following registration was delivered per routine practice.

Patients who provided electronic consent during self-scheduling were sent a post-discharge survey 24 hours later via REDCap to assess satisfaction with the MAPP process.

Participants

All consecutive patients meeting the following criteria during the study period were included in the MAPP group: (1) a valid Ontario Health Insurance Plan number; (2) an active email address; (3) age ≥18 years or, if a minor, parental consent and assent as applicable; (4) completion of the screening questionnaire for musculoskeletal-patient assessment tool (Barrie M-PAT) or cold and influenza-patient assessment tool symptoms (Barrie C-PAT) (online supplemental section 2.0).

The comparison group (UC) included all consecutive patients who were seen by a physician in the main ED during the same period. Patients who left without being seen or without a documented discharge or admission were excluded. Patients were categorised into three groups: (1) LANA (CTAS 4–5, not admitted); (2) high-acuity, non-admitted (HANA; CTAS 1–3, not admitted) or ED admit (any CTAS Score admitted to the hospital).

Data sources and variables

Data for MAPP patients were extracted from REDCap. Clinical, operational and follow-up data were retrieved from RVH’s electronic health record ED scheduling system and Decision Support Unit. 7-day return visit data were obtained from routinely collected ED records. The primary outcome was ED LOS, defined as time in hours from in-person triage or registration (whichever occurred first) to discharge. Time to PIA was similarly defined as time from in-person triage or registration to first documented physician contact. CTAS classifications were used to stratify patient acuity. Covariate definitions used in regression modelling are provided in online supplemental section 3.0.

Bias mitigation

To reduce bias inherent in observational design, all consecutive MAPP patients were prospectively enrolled and compared with a contemporaneous control group. This approach accounted for seasonal variation and changes in ED demand. Analyses were stratified by CTAS to minimise confounding by acuity. Multilevel modelling further adjusted for clustering and operational variables including ED staffing levels and daily patient volume.

Sample size and power

The study was powered to detect a minimal clinically important difference (MCID) of 1.5 hours in ED LOS, the upper 95% CI of RVH’s historical gap in mean LOS for LANA patients versus the provincial average 2015–2023. The mean RVH LANA LOS from this prestudy time period was 5.9 hours, making the target MAPP LOS 4.4 hours. Assuming 25 ED MAPP patients per weekday and that 75% would be LANA, approximately 20 ED MAPP LANA patients were expected daily. In the comparison group, ~65 LANA patients were seen per day. Power calculations indicated that 1 week of observation period would yield 99% power to detect the MCID (α=0.05, SD=2.0 hours). The study was considered complete once the estimated sample size was met and the MAPP study team confirmed that all required implementation adaptations had been addressed.

Statistical methods

Baseline characteristics were summarised using descriptive statistics. Continuous variables were reported as means with SDs or medians with IQRs and categorical variables as frequencies and percentages. Between-group comparisons used t-tests or Mann-Whitney U tests for continuous variables and χ² tests for categorical variables.

Multilevel, mixed-effects linear regression models were used to compare ED LOS and PIA between groups. Patients (level 0) were nested within diagnoses (level 1), ED physician (level 2) and care area (level 3). Models adjusted for both patient-level and system-level covariates. Secondary outcomes were exploratory and were not adjusted for multiple comparisons. Missing data were not imputed, with all analyses using complete case data. All statistical analyses were conducted using STATA V.18.0 for Mac.

Patient and public involvement

Not applicable.

Results

Participants

During the study period, RVH received 73 132 total ED visits, of which 2766 (3.8%) were completed by patients who underwent self-triage and scheduled their arrival using MAPP (table 1). Consistent with the MAPP’s focus on low-acuity presentations, most visits were for cold and influenza symptoms (63.6%) or musculoskeletal complaints (18.4%). The remainder, categorised as ‘Other’, included patients with various other diagnoses, as well as those who did not self-book but were either scheduled for follow-up by MAPP healthcare providers (eg, for intravenous therapy or diagnostic imaging) or redirected to the Pink Zone by the main ED triage nurse (table 1).

Table 1. Distribution of ED patients by study phase and diagnoses.

Phase (Patient type)	Diagnoses (n (% of total))
	MSK	Cold and influenza	Other*	Total
1 (1 June to 26 September 2023)
UC	4789 (6.81)	3887 (5.52)	19 780 (28.11)	28 456 (40.44)
MAPP	1 (0.00)	25 (0.03)	109 (0.15)	135 (0.18)
2 (27 September 2023 to 31 March 2024)
UC	5804 (7.94)	7259 (9.93)	28 847 (39.45)	41 910 (57.31)
MAPP	509 (0.7)	1734 (2.37)	388 (0.53)	2631 (3.6)

^*Other represents all other diagnostic categories for ED patients, but represents musculoskeletal (MSK) or cold and influenza diagnoses for MAPP patients who did not self-book but were either scheduled for follow-up by the MAPP healthcare providers for intravenous drug treatment or diagnostic imaging or were sent from the main ED to the Pink Zone by the ED triage nurse.

ED, emergency department; MAPP, Minor Ailment Patient Pathway; n, number of patients; UC, usual care.

All patients were categorised as either LANA, HANA or ED admit, consistent with Ontario Health classifications used in Pay-for-Results (P4R) reporting (table 2). The majority of MAPP patients were classified as HANA (65.2%), followed by LANA (34.0%), with only 0.8% requiring hospital admission. In contrast, 13.6% of UC patients were admitted to hospital.

Table 2. Distribution of ED patients by acuity, disposition and diagnoses.

P4R category (Patient type)	Diagnoses (n (% of total))
	MSK	Cold and influenza	Other*	Total
LANA
UC	3320 (4.54)	1481 (2.03)	6607 (9.03)	11 408 (15.6)
MAPP	244 (0.33)	541 (0.74)	156 (0.21)	941 (1.29)
HANA
UC	6742 (9.22)	9531 (13.03)	33 090 (45.25)	49 363 (67.50)
MAPP	266 (0.36)	1217 (1.66)	320 (0.44)	1803 (2.47)
ED admit
UC	531 (0.73)	134 (0.18)	8930 (12.21)	9595 (13.12)
MAPP	0 (0)	1 (0.00)	21 (0.03)	22 (0.03)

^*Other represents all other diagnostic categories for ED patients, but represents musculoskeletal (MSK) or cold and influenza diagnoses for MAPP patients who did not self-book but were either scheduled for follow-up by the MAPP healthcare providers for intravenous drug treatment or diagnostic imaging, or were sent from the main ED to the Pink Zone by the ED triage nurse.

ED, emergency department; HANA, high-acuity, non-admitted; LANA, low-acuity, non-admitted; MAPP, Minor Ailment Patient Pathway; n, number of patients; P4R, Pay-for-Results; UC, usual care.

Baseline characteristics differed significantly between UC and MAPP patients across all acuity and disposition categories (online supplemental section 4.0). MAPP patients were generally younger, more likely to present with cold and influenza symptoms, and more often had a family physician than UC patients. Among LANA and HANA visits, MAPP patients had fewer prior ED visits in the preceding 12 months. Hospital admission from MAPP was rare, and overall, MAPP patients were almost exclusively triaged as CTAS 3–5, whereas the UC group expectantly included a significant proportion of CTAS 1–2 cases.

Over the study period, the median daily volume was 15 MAPP patients (IQR 22) and 249 UC patients (IQR 31), with maximums of 40 and 312 visits, respectively. Daily staffing of the entire emergency team throughout the study period included a median of 94 (IQR 15) ED physician hours, 37 (IQR 6) registered nursing shifts, 6 (IQR 3) registered nursing assistant shifts and a mean of 8.33 (SD 12.8) physician assistant hours. Given the cross-sectional, nested structure of the patient-level outcome data (level 0), there were a total of 3150 different diagnostic codes (level 1), 129 ED physicians (level 2) and 7 different ED locations (level 3) used over the study period. There was a daily median of 31 (IQR 8) admitted patients to the ED awaiting transfer to the hospital wards.

For MAPP patients, there were 3637 self-scheduled arrival times, with a no-show rate of 23.9%, with highest ORs for no-shows seen in patients 12–18 years (OR 1.60) and over 65 years (OR 1.60) compared with a baseline group patients less than 1 year old. No-show rates did not differ by diagnosis or month of arrival date. Most MAPP patients (79.86%) scheduled a single visit over the study period, 14.3% scheduled two, 3.8% scheduled three and 1.0% scheduled four or more, with a maximum of 14 self-schedule visits.

LOS and physician initial assessment

Among LANA patients, the unadjusted mean LOS was 1.82 hours longer in the UC group than in the MAPP group (95% CI 1.74 to 1.89), most of which was attributable to shorter PIA time (table 3). Across all categories, unadjusted LOS was significantly shorter for MAPP patients, with largest differences observed in HANA and ED admit MAPP patients, although these were less strongly driven by PIA time reductions than in LANA patients. Unadjusted PIA was significantly shorter across all categories except for admitted patients, with all PIA times across all categories less than 1.6 hours.

Table 3. Comparison between unadjusted mean LOS and PIA for ED and ED MAPP patients by P4R category.

P4R category	Wait time (mean hours (SD))
	ED UC	ED MAPP	Difference	95% CI
LANA
LOS	3.12 (2.22)	1.30 (1.01)	1.82	(1.74 to 1.89)
PIA	1.76 (1.40)	0.39 (0.43)	1.37	(1.33 to 1.41)
HANA
LOS	4.82 (3.28)	1.70 (1.63)	3.12	(3.04 to 3.20)
PIA	2.22 (1.69)	0.62 (0.89)	1.6	(1.55 to 1.64)
ED admit
LOS	21.66 (86.07)	12.63 (8.91)	9.03	(4.76 to 13.29)
PIA	2.34 (13.89)	1.93 (1.67)	0.41	(−0.41 to 1.23)

ED, emergency department; HANA, high-acuity, non-admitted; LANA, low-acuity, non-admitted; LOS, length of stay; MAPP, Minor Ailment Patient Pathway; PIA, physician initial assessment; P4R, Pay-for-Results.

In the multilevel, multivariate regression model (online supplemental section 5.0), adjusted differences for LANA patients were smaller, but remained statistically significant, with a mean LOS 0.44 hours shorter than in the UC group (95% CI 0.046 to 0.842) (figure 1). Adjusted PIA times did not differ across categories among MAPP patients, but were significantly faster than those of the UC patients by at least 1.1 hours across all P4R categories.

Figure 1. Adjusted LOS and PIA for ED and ED MAPP P4R categories.

The adjusted analysis suggested a longer interval between PIA and discharge for MAPP patients, attenuating the overall LOS difference seen in the unadjusted analyses. In the fully specified model, 56.1% (95% CI 42.9% to 68.5%) of total LOS was attributable to clustering at higher levels (diagnosis, physician and location), with significant contributions from each level (12.9% to 27.3%), suggesting these factors should be accounted for in future implementation-effectiveness studies.

Safety

Monitoring for patient safety signals included measuring the number of repeat visits within 7 days of an ED visit, along with the subsequent rate of hospital admissions for those repeat ED visits. For MAPP patients, 8.49% of patients returned to the ED within 7 days, compared with 10.7% of UC patients, a reduction of 2.26% (95% CI 1.16% to 3.35%) among MAPP patients. If we exclude repeat ED visits within the first 48 hours which are usually due to scheduled return visits for treatments or diagnostic imaging, 3.18% of MAPP patients compared with 4.43% of UC patients had a return visit, a reduction of 1.26% (95% CI 0.57% to 1.95%) among MAPP patients. For those who returned to the ED, only 1.8% of MAPP patients were admitted to hospital compared with 13.2% of UC patients, a reduction of 11.4% (95% CI 9.50% to 13.33%) among MAPP patients.

Patient satisfaction

Of the 2217 MAPP patients who consented to a follow-up, 29.1% responded to an electronic survey sent 24 hours after their visit. More than 95% rated the self-triage and scheduling platform easy or very easy to use, and a similar proportion were satisfied or very satisfied with their ED visit.

Interpretation

Patient and provider experience

Compared with CTAS-matched patients receiving UC, MAPP use was associated with shorter LOS, faster PIA, lower rates of 7-day return visits and admissions, and exceptionally high patient satisfaction, exceeding 95%, a threshold rarely achieved in emergency care. These findings suggest that patient-initiated, technology-enabled pathways can improve ED flow and experience without compromising safety.

While MAPP was designed for patients with CTAS 4 and 5 presentations, we found a substantial proportion were triaged as CTAS 3 on arrival. This likely reflects both the subjective nature of self-reported symptoms and the variability inherent in triage assignment, particularly for respiratory complaints. Importantly, even among these moderately urgent cases, safety outcomes remained favourable, suggesting that the model may be adaptable to a slightly broader range of low-acuity to moderate-acuity presentations.

Survey responses frequently emphasised the benefit of avoiding prolonged waits, particularly for families with young children. While most MAPP and ED patients reported having access to a primary care provider, MAPP patients were more likely to report having a family physician. This should not be interpreted as evidence that their ED visits were necessarily avoidable through primary care alone. In Canada, attachment to a family physician does not ensure timely same-day, next-day, evening or weekend access for urgent low-acuity concerns. In addition, most family medicine offices do not provide on-site diagnostic imaging or laboratory testing, which may be particularly relevant for cold and influenza and musculoskeletal ailments. These factors may help explain why patients with a family physician still sought ED care and support interpreting MAPP as an ED flow intervention rather than as a substitute for primary care.

Operational integration and workforce efficiency

Beyond improvements in flow, MAPP was associated with operational efficiencies. Because patients arrived with structured symptom input and had been prescreened for eligibility, arrival procedures appeared to be safely managed by a registered practical nurse (RPN), rather than a registered nurse. This change in staffing mix may help to optimise health human resources, particularly as EDs continue to face staffing challenges. From a process standpoint, MAPP front-loaded key intake steps, including triage information and arrival time selection, associated with a reduced demand at the triage desk that could lead to smoothing arrival patterns during off-peak periods and potentially enabling caregivers to better anticipate and allocate daily resource needs.

Comparisons with existing literature

Although several self-triage systems were developed and deployed during the COVID-19 pandemic to help manage demand and reduce in-person visits across provider settings,¹⁸ they remain infrequently implemented in routine care. Unlike self-triage, most digital interventions in urgent and emergency care have fallen into three broad categories: symptom checkers, which direct patients to appropriate settings based on reported symptoms; asynchronous booking tools, which typically let patients request appointments without clinical assessment; and virtual care referral platforms, which direct patients to telemedicine or other remote services.¹⁹,²² While these tools improve access, they typically operate outside of live ED workflows and true patient-initiated self-triage remains rare in real-world emergency care.²³,²⁵

A recent Canadian study by Trivedi et al evaluated two proprietary self-triage tools in live ED settings and found poor agreement with nurse-assigned CTAS scores, concluding that self-triage was not yet viable for broad ED use.¹⁶ In contrast, structured digital tools used in narrowly defined low-acuity populations, such as the Swiss Medical Assessment System (SMASS), have demonstrated high safety and minimal under-triage. A large prospective study found that SMASS resulted in no potentially hazardous under-triage and a very low rate of false reassurance.²⁰ As these tools are implemented, developing triage algorithms with high specificity, particularly to avoid misclassification of high-risk patients, remains a critical component of safe and effective self-triage design.²⁴

Unlike prior tools that primarily function as standalone symptom checkers or referral platforms, MAPP is a purpose-built digital pathway that combines structured self-triage with real-time appointment scheduling and full integration into live ED workflows. It operates under clearly defined inclusion and exclusion criteria overseen by clinical staff, offering a more operationally embedded model than has been previously described. To our knowledge, no prior study has prospectively evaluated a self-triage platform with direct integration into day-to-day ED operations. This approach may represent a novel and scalable framework for managing low-acuity demand without diverting patients away from emergency care.

Limitations and generalisability

This study was conducted at a single site, during off-peak hours, and focused on a limited set of presentations which all limit the relevance of its findings to other EDs. Uptake was modest and approximately one in four scheduled patients did not present, limiting generalisability and real-world efficiency estimates. However, in this implementation, MAPP and the main ED shared the same staffing complement, rather than functioning as a separately staffed service. As a result, missed MAPP appointments did not necessarily translate into entirely idle dedicated staff, because staff could continue to support the usual ED operations. Nevertheless, an attempt to reduce no-shows with appointment reminders that enable re-scheduling or cancel options has been implemented. We did not capture long-term outcomes or primary care attachment status. While we did capture validated ED safety metrics for the study population, we did not use population-level data to link the unique healthcare numbers of each study subject to other potential healthcare use external to the study site, thus limiting the completeness of our safety assessment to ED returns or hospital admissions to local hospital data. The non-randomised design also introduces the potential for selection bias and residual confounding. The extremely positive patient experience captured by the post-MAPP visit survey was limited in its generalisability due to the low response rate, which may have introduced positive response bias. However, the post-study utilisation of MAPP continues unabated, with ever increasing patient utilisation with increasing diagnostic categories, now having cared for over 10 000 patients since its initial inception and implemented in four other Ontario hospitals, all suggesting that the patient experience captured by our study surveys is likely representative of the population at large.

ED volumes in Ontario are coded in the National Ambulatory Care Reporting System (NACRS) as “unscheduled” visits.²⁶ The current definition for a “scheduled” visit is a visit with a fixed appointment time recorded in a scheduling system.²⁶ In this study, MAPP visits were considered “unscheduled” by the investigators because patients booked an arrival time and not an appointment time, in a manner similar to ED return visits for intravenous antibiotics and follow-up diagnostic care. The actual time MAPP patients would be seen was dependent on main ED staffing, patient volume and acuity because of the integration of the MAPP and ED staffing. The investigators acknowledge the classification of MAPP patients as “unscheduled” may be judged by some to violate the current NACRS criteria.

Nonetheless, MAPP’s low operational complexity, high patient satisfaction, safe RPN-led arrival and alignment with broader health system priorities support its potential applicability in other settings. With early expansion to a second Ontario ED yielded similar reductions in LOS and favourable patient feedback (personal communication, Dr Greg Devet, Collingwood General and Marine Hospital) and several hospitals expressing interest in local adaptation, a multisite evaluation is planned in response to ongoing pressures on ED capacity and the growing need for innovative approaches to managing low-acuity demand. These efforts are aligned with provincial priorities to scale innovative models that safely divert non-urgent care from EDs.⁶

Conclusion

MAPP suggests that a combined digital self-triage and self-scheduling digital pathway can improve ED flow, enhance the patient experience, and support more flexible staffing models without evidence of short-term harm. As low-acuity visits continue to strain acute care capacity, particularly for underserved patients and families, this model supports an emerging shift toward patient-initiated, digital front-door solutions for timely, unscheduled care.

Data availability statement

Data are available upon reasonable request.