Recently, and to the horror of emergency physicians all across the country, a homicide charge was filed against a hospital emergency department in Illinois, according to the Associated Press.
The case went like this: A 49-year-old woman presented to triage complaining of chest pain. She was triaged as semi-urgent, but sent back to the waiting room. She was not immediately seen by a physician. According to the records, she sat in the waiting room for more than two hours. When a nurse finally went to bring her back for evaluation and care, she was apneic and pulseless in the waiting room. Resuscitation was unsuccessful, and a subsequent homicide charge was filed against the emergency department of Vista Medical Center East in Waukegan, IL.
Timely care is an issue front and center for U.S. emergency departments. The Joint Commission on Accreditation in Healthcare Organizations' so-called flow standard is mandating that departments demonstrate efforts to study and improve patient flow. The debate about overcrowding has given way to dialogue about patient flow: how to measure and improve it. For the first time, a set of standardized definitions and benchmarks have been proposed for emergency medicine, which help get a handle on elusive patient flow. (Welch SJ, Acad Emerg Med 2006, at press.)
Timeliness of care is among the strongest correlates with patient satisfaction. (Ann Emerg Med 1993;22:586 and 1996;28:657.) In particular, the time it takes to see a physician (door-to-doctor time) has the best correlation of all. (J Emerg Med 1997;15:397; J Health Care Mark 1993;14:26.) By moving patients quickly to patient care areas and having physicians evaluate them in a timely fashion (under 30 minutes is the service quality goal), patients perceive that the wait time is acceptable. (Ann Emerg Med 1993;22:586; Health Care Manager 2002;21:46.) When the time interval from triage to physician evaluation goes up, the rate of patients leaving without being seen goes up linearly. (Ann Emerg Med 1999;34:3.)
Many EDs process patients from arrival to physician contact in a manner similar to the flow diagram shown. This manner of processing patients adds waits and delays, and as can be seen from the diagram, very few steps hold any intrinsic value to the patient. Traditional triage as a process may be obsolete. When an average ED had an annual census of 18,000 visits, triage made sense. A nurse could assess a patient, determine acuity, and place the patient in the ED queue. Now, however, the average ED has 40,000 visits a year, and patients pass through a large bottleneck (occurring daily in thousands of emergency departments). And it is of our own design! The world comes to the ED, and even when beds and staff are available for immediate treatment, we make our patients pass through this bottleneck where typically one nurse does an assessment before moving the patient to a patient care area.
The Institute for Healthcare Improvement, through its ED Collaborative, is encouraging emergency departments to think outside the box, and a number of alternatives to traditional triage are being investigated. There also has been a mini-explosion in the literature over the past 24 months of published articles describing alternatives to traditional triage. A few of these are described in the table.
The trend has been to elevate the level of education and experience of the person in triage. From midlevel providers to emergency medicine attendings, this change has uniformly resulted in reduced throughput time, reduced waits, and reduced walkaways. In 2004 a British team was among the earliest to suggest innovations such as advanced triage protocols, care teams, and multidisciplinary triage in an article titled, “A Paradigm Shift in the Nature of Care Provision in the Emergency Department.” (Emerg Med J 2004;21:681.)
Since then, many facilities have been experimenting with triage alternatives like team triage. Several authors have described success with having a team, often a physician, nurse, and technician, converge at the bedside to take the triage history together and formulate a diagnostic/therapeutic plan. (Emerg Med J 2004;21:542; Ann Emerg Med 2005;46:499; Emerg Med Australia 2006;18:391.) Other institutions have described putting a physician in triage. In the so-called TRIAD study (Triage Rapid Initial Assessment by Doctor), the throughput time was decreased by 38 percent with no increase in staff. (Emerg Med J 2006;23:262.)
Finally, Theodore Chan, MD, and James Killean, MD, in San Diego have reported the most radical departure from traditional triage: No triage! If there is a bed in the department, the patient is brought back to a patient care space, and using advanced triage protocols and bedside registration, care of the patient begins. This has led to reduced patient waits, decreased overall length of stay, and reduced numbers of patients leaving without being seen. (Ann Emerg Med 2005;6:491.)
The point is this: When the patient woke up that morning, he did not decide to come to the emergency department to see a triage nurse, a triage EMT, or a registration clerk. He came to the emergency department to see an emergency physician! Anything which can be done to expedite that encounter and decrease the waits and delays should be embraced. Any impediments to the patient physician encounter should be reduced or eliminated.
The benefits of this are threefold. In terms of risk reduction, the more quickly a physician can get to a patient and assess his acuity and status, the less chance that a delay will harm the patient or affect his outcome. Increasingly evidence-based medicine shows us clinical entities with time-dependent elements to their care (door-to-balloon time in acute MI, thrombolytics in stroke, antibiotics in community-acquired pneumonia, the golden hour of trauma). These time-dependent goals may dramatically influence clinical outcomes, but can only be met if the delay in seeing the physician is kept to a minimum. Last but not least, the amount of evidence linking waiting time to see a physician with walkaways and overall patient satisfaction is quite compelling. If you make one change in your department this year, let the focus be on door-to-doctor time. Remember all patients really want is you!
ALTERNATIVES TO TRADITIONAL TRIAGE
▪ Midlevel provider in triage
▪ Physician in triage
▪ Team triage
▪ No triage