It's not that Ellen J. Weber, MD, is opposed to triage. It's just that the University of California, San Francisco, professor of emergency medicine said she worries that triage might be slowing the process of moving patients from the waiting room to treatment, even preventing the sickest from getting timely care. And she has the data that might just prove it.
Not even half of the high-acuity patients in her urban emergency department completed triage in the 10 minutes or less recommended by the five-tier emergency severity index used in their facility. As she and her colleagues, Ian McAlpine and Barbara Grimes, PhD, recounted in a recent study, the average time from arrival to completion of triage was 12.3 minutes, with a range of 0 minutes to an astounding 128 minutes. (Ann Emerg Med 2011 Apr 23. [Epub ahead of print].) The investigators studied various triage measures for 3,932 high-acuity walk-in patients, 63 of whom fell into the most severe category of emergency severity index 1 and the remaining 3,869 into emergency severity index 2.
Twenty-seven percent of those walk-ins were taken right to a room on arrival, and 41 percent, including those who went to a room immediately, completed triage within 10 minutes. Triage took longer than 20 minutes for 25 percent of patients and longer than 30 minutes for 10 percent. Triage took longer for ESI-2 patients, and fewer met the criteria of the severity index between 10 a.m. and 10 p.m.
“We were not surprised by the findings,” said Dr. Weber. “I think many physicians feel that triage is taking too long. We've all had the experience of having time to see patients and finding that they are still in triage.”
Dr. Weber initiated the study because of her experiences in England where the Department of Health has set the target of getting patients through the emergency department within four hours. Accident and emergency departments there eliminated detailed triage and acuity ratings to meet that goal, she said.
“They substituted a system where there were two triage acuities: see now, see later,” she said. “If you come by ambulance or walk in with chest pain, you are immediately put in a treatment area. You need to be seen. There is no acuity rating. Once you are there, the nurse tells the doctor who should go first. The other group — the walk-ins who are not fast-tracked — had to wait their turn.”
“Waiting their turn” may be a simplification of the process. As Dr. Weber tells it: “They had to sign in. They might see a registration clerk who tells [them] to take a seat. Then an assessment nurse selectively picks people in the waiting room to see who needs pain medications, to make sure that someone does not need to go right back. If someone has been waiting a long time, the nurse does an assessment to see if it is OK to wait. They don't assess every patient, and they don't do a full set of vital signs, medical history, etc. It is up to the nurse to decide who to see and how much to do.”
Triage should not create “another pew” for waiting patients, Dr. Weber said, where it slows down the treatment process. “We've all had the situation of empty rooms in the department and a nurse to staff them, but instead the patient is still in triage. In the best of circumstances, that takes 10 to 15 minutes when there is a nurse in the back who could see them if they are in a room.”
The process may be in need of an overhaul, with Dr. Weber questioning whether the information collected at triage is used appropriately. A nurse in triage puts the patient's information on paper and transfers him to an exam room, where he begins the process again with another nurse. “If the nurse wants to do a good reassessment and check everything, the patient starts to get frustrated, and say he has already told someone this. It can be inefficient and a safety problem,” she said.
A lot of the information might be collected in triage for reasons other than determining acuity, she said. “Why are we doing it there?”
Consideration of triage procedures is important in an era when patients are unwilling to wait even an hour to see a physician, said Shari Welch, MD, of the Intermountain Institute for Health Care Delivery Research in Salt Lake City, UT, who with Steven J. Davidson, MD, wrote an editorial accompanying Dr. Weber's article in Annals. (Ann Emerg Med 2011 May 19. [Epub ahead of print].) “We understand that the world has changed,” she said, and that “we are reaching a tipping point.”
Installing a physician in triage is an idea Dr. Welch supports because doctors are good at identifying patients who are sick. “They can say ‘sick, not sick' quickly and with accuracy,” she said. “Why on earth would you put all these other people between the patients and the doctor? I'm a believer in triage protocols, but the physicians need to get in there.”
That kind of system could even extend the careers of physicians as they near retirement, she said. One doctor told her if he had that kind of opportunity, it would mean a new lease on his career.
Dr. Weber is dismayed by the paradox. “Triage is there for when it's crowded, to help decide who goes first. What concerns me is that triage might contribute to crowding by creating a backlog over the course of time. You start in the morning with empty rooms, and everyone gets triaged. It is soon backed up with people who need treatment quickly but who are behind people who have not gotten into rooms.”
She said she is not convinced that putting a physician at triage is cost-effective or any better at making quick decisions about acuity than nurses. “The advantage of having a physician at triage is to start the workup sooner. They are not more accurate than nurses in terms of thinking someone is sick or not, but they can start things earlier,” Dr. Weber said. “Triage is a block, and this way, instead of getting the physician to the patient sooner, we are going to move the physician up front.”
UCSF has tried having a physician in triage, as have other emergency departments, and patients are happier because they see a doctor sooner. “I'm saying, why are we doing that in the triage area?” Dr. Weber asked. “Why don't we just put them in the treatment area, and do it there?”
EDs need to use the systems and space they have more efficiently. “Whenever there is an empty room, you should bypass triage,” she said. “Why not just put people in empty spaces, and have someone see them? If you get to the provider quickly, that person can decide if you need vital signs taken. It should be up to me as a provider whether I want a temperature or pulse oximetry. We need the willingness to allow people to use clinical judgment and believe the patient.”
Of course, when the ED is so busy that no rooms are available, some screening is necessary, Dr. Weber said. “How much would the busyness go away if you got people into the emergency department and let the providers decide about the assessment? Use the nursing staff in ways that help you do the life-saving treatments instead of the assessments,” she said.
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Innovations to Relieve the Triage Bottleneck
Physical Plant Changes
* Cubicles for physicians to assess patients in a less formal setting.
* Triage pods and a special team of physicians, two physician assistants, and four nurses who assess patients and move them to an appropriate space in under 15 minutes.
* Recliner area where patients are directed at intake and where the medical team can see patients.
* Internal waiting room called the post-screening area.
* Computerized tool that is filled out automatically if the patient was seen previously in the ED.
* A palm scanner to create a biomedical identification that ties each patient to an identification number. Later, that number is associated with demographic data. The palm scan insures that the patient is associated with the proper medical identification number.
* Telemedicine to triage patients in nursing homes and extended care facilities, often avoiding a visit to the emergency department or getting very ill patients to the department quickly.
* Radio communicator to call a physician to triage to assess patients and start workup.
Process or Flow Changes
* A scribe program to reduce clerical and documentation burdens on physicians.
* Varied intake method depending on volume of patients coming to the emergency department.
* Stationing a physician in triage to decide who should be seen immediately and who should be seen later.
* Patient streaming/patient segmentation. The sickest patients are seen quickly by a physician, but less sick patients are not undressed or bedded, but instead seen as though they are in a clinic.
* The Philadelphia EMS Admission Rule (PEAR) developed by the University of Pennsylvania to help EMS providers predict whether patients need to be admitted.
Source: J Emerg Med 2011 May 26. (Epub ahead of print).