Triage 2.0

Published on July 13, 2015
Triage is a big part of what happens at the front door of many EDs, and it is thought to be essential for safe practice and smooth patient flow by many ED clinicians. But is there a better way?

Over the last decade, after reviewing emergency systems in many countries, I have realized how little attention doctors place on the entrance and reception areas of their EDs.

The paramedics, nurses, and clerks “own” the processes; doctors generally don’t (and don’t want to). Yet many of our clinical delays, critical incidents, patient complaints, and overcrowding issues result from processes that begin at the front door. There are industrial/political reasons for this (each discipline wants control), and convenience—it is easiest for the doctor to just see the patient when they are in the bed in the ED and “packaged.” Triage is a big part of what happens at the front door of many EDs, and it is thought to be essential for safe practice and smooth patient flow by many ED clinicians.

The question I would like to pose is: has the adoption and formalization of triage by EDs resulted in better outcomes for emergency patients? In the early days of emergency medicine, working in the ED may well have seemed like a disaster situation with inadequate resources and surges in demand that could not be managed in a systematic way. So some form of damage limitation process may have seemed sensible. In first world systems of care for emergency patients, does the paradigm of an on-field disaster fit with the sophistication of the medicine we are trying to deliver in the 21st century?

The formalization of triage as a process supposedly dates back to the Napoleonic wars, where doctors were overwhelmed by incoming casualties and had to make tough decisions regarding salvageability. This concept has been adopted and embellished by disaster medicine groups who have taught the world the importance of classifying a large number of casualties to ensure the greatest good for the greatest number. Casualties are quickly color coded with triage tags according to red (immediate life threat), yellow (urgent), and green (walking wounded), with black reserved for those thought to be dead or unsalvageable. The logic behind using this classification on the battle field or in a disaster situation has some merit, but even in this context attitudes are changing, with rapid evacuation now the ultimate goal. It is very difficult to determine the extent and salvageability of injuries on the field, and it is likely that more lives would be saved by all casualties being evacuated quickly.

In modern emergency systems, there are now clinical pathways for many emergencies where we effectively stream from the field to the operating room, trauma room, catheter lab, or CT scanner (eg, for stroke). Including a triage process at the door of the ED can only slow this process.

The adoption of this disaster/battlefield concept to the ED resulted in many versions of ED triage. English-speaking countries have been most enthusiastic, and the “science” of triage has developed further, particularly in the UK, Australia, Canada, and some parts of the USA. The most popular forms are five-point scales with category 1 being urgent and life-threatening and, category 5 being non-urgent. The major criterion for categorization in most scales is time urgency to be seen. In the US, however, the Emergency Severity Index (ESI) combines the concepts of severity and urgency. The process of triaging a patient can take more than 10 minutes and will almost always add a few minutes to the process of admitting the patient to the ED. When 10–20 patients arrive in a short space of time, this ensures a lengthy delay!

The triage process had a number of potentially beneficial spin offs, including the administrative benefit of being able to determine casemix funding according to triage. Resource usage closely follows urgency category. It was also useful as a means of getting some structure around clinical quality indicators for waiting times. Waiting 20 minutes with a major trauma is very different than waiting 20 minutes for a cut finger.

In modern emergency systems, there are now clinical pathways for many emergencies where we effectively stream from the field to the operating room, trauma room, catheter lab, or CT scanner (eg, for stroke). Including a triage process at the door of the ED can only slow this process. At the other end of the spectrum of time urgency, there are many patients with minor conditions who could be definitively managed within minutes of arrival by an appropriately trained nurse or physicians assistant, if they could be safely streamed to a dedicated area. A formal triage process can only delay this, and adds another hurdle to the patient receiving the care that they came for.

The middle group of patients, who don’t fit defined clinical pathways and are not clearly resuscitation or ambulatory/fast track, are usually classified as Cat 2,3,4 in the various triage systems. These compose the majority of sick patients and represent the greatest risk to the ED. The triage systems attempt to arbitrarily tease out whether these patients should be seen within 10 minutes to an hour. The triage nurse systematically asks questions in attempt to avoid unsafe practice (such as an AMI or subarachnoid hemorrhage) waiting in the waiting area for a prolonged period, potentially resulting in unnecessary complications. The problem with this approach is that what is really required is rapid initial assessment by a doctor, to quickly rule out the “red flags,” begin investigations, and ensure that essential initial treatments, such as analgesia and antibiotics, are given. Many patients with incipient septic shock, AMI, and stroke present with vague symptoms. Triage only delays the symptomatic management and definitive treatment of this ill-defined group.

So who benefits from triage? The patients certainly don’t—they get left in the waiting room with no analgesia or other symptomatic relief, and receive delayed management of simple conditions. In fact, in many EDs there is almost a punitive element to triage for the patients, in that a Cat 5 “should wait” as they are “non-urgent.” Some doctors may like triage because it makes for an easier shift, in that workload is more orderly and rapid decisions regarding treatment priorities can be delayed. The nurses in those systems with triage like it because it means they have some control over processing and patient flow. However, the inherent delays caused by the triage process, especially before triage, are not necessarily acknowledged as they are not easily measured.

If there is no triage, how does one create order from the potential chaos of an ED? Many EDs have introduced “streaming” to ensure that patients are seen by the appropriate person in the appropriate area in the fastest time. This means that if a patient fits a clinical pathway, such as major trauma activation, stroke, septic shock, or STEMI, then they are taken to those areas and teams are activated. Ambulatory patients without red flags are streamed to fast track areas where they are seen immediately by nurse practitioners or equivalent. The “cubicle” patients are assessed in a rapid initial assessment area, and initial symptomatic treatments, investigations, and agreed clinical pathways are initiated.

In the “streaming” model there are no real delays for initial assessment and life-threatening emergencies. Patients are happier because they are seen quickly and symptomatic treatment is started early. What does triage add to this?

Surely it is time to stop this form of disaster management and develop 21st century emergency systems of care.

Dr. Peter Cameron is the immediate past president of the International Federation for Emergency Medicine (IFEM)

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