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Letter to the Editor: Eliminating Triage Causes Problems

doi: 10.1097/01.EEM.0000449786.98352.46
Letter to the Editor


It pained me to read “The End of the ED Waiting Room.” (EMN 2014;36[1]:1; Publishing these types of articles, along with the misrepresentation of data, is an insult to emergency medicine providers across the globe. It encourages patients to bully providers while the art of medicine is lost in translation.

The fundamental concept of triage as practiced in EDs is to sort patients and to control chaos. Patients do not show up one at a time over the course of a few hours. Instead, they come in groups. Patient care should be expedited for those who need immediate attention. Areas are designated for different levels of acuity, and it does matter where patients go. The no-triage concept quickly fills exam rooms with patients who come for nonemergent complaints. Prime examples include but are not limited to patients seeking prescription refills and those complaining of toe pain they have had for 12 years. These patients occupy a spot in the ED that could have been used for a time-sensitive patient like those with stroke within the window for tPA, those with MI who could go to the cath lab faster, and a septic patient who needed antibiotics sooner. It simply does not make any sense to eliminate a sorting system that has so carefully and prudently helped provide safe care to millions of patients over time. Eliminating triage doesn't solve problems; it causes problems.

Doing away with triage is unrealistic, downright foolish, and unsafe. Comparing ED triage with the supermarket and car wash is ridiculous, and I find this statement utterly insulting. Health care systems pushing for the-customer-is-always-right mentality are mistaken. Hospitals are not fast food joints, and the customer is not always right. Medical care and treatment plans are an art and a science that need to be respected. Providing the public with a false sense of “a more enjoyable visit” by making it “faster” is not and should not be acceptable. Since when did our catchphrase become “satisfaction guaranteed?” What happened to “first, do no harm?”

Most of the people advocating for the complete dismissal of triage are not actually people who work the daily grind. They are not people who get slammed with three critically ill patients in five minutes. They are not people who work shifts, and see inappropriate patients placed in hallway beds just to see a provider sooner. These patients ultimately suffer because the proper attention and staffing are not initially provided. This is because they were not appropriately triaged. Keep in mind that most EDs don't staff their departments with an appropriate number of providers, nursing staff, and technicians to embrace any thought of “direct bedding.” Patients are given a false sense of security when directed to the back as soon as they arrive. Most of the time direct bedding is not possible because staffing does not allow it nor does the facility support it. More registration “greeters” are always ready to grab the bill than there are true medical providers available to treat medical disasters. And how does this protect your staff legally? It's really just setting them up for mistakes. Eliminating triage is bad for your ED providers. What happens when nurses don't chart vitals signs or true complaints? How do you ensure these crucial steps are completed without the triage process? The solution is not eliminating a fundamental process that is not broken; it is hiring more staff and creating more space, neither of which 99 percent of hospital CEOs will do. Why are we trying to reinvent the wheel?

The study cited from the Brigham and Women's ED does not provide a leg to stand on. It was replicated at several facilities with higher acuity, less space, and longer waits. The study was shown to have several flaws, and could not be reproduced by most facilities across the United States. Hundreds of well-researched, evidenced-based studies prove triage improves patient flow, meets staff and hospital safety goals, improves staff morale, and helps meet time-sensitive Joint Commission standards for pneumonia, sepsis, MI, and stroke. Triage allows for better outcomes for all patients, especially critically ill populations. I could go on, but I'll let you do your own Cochrane database search.

I guess what it boils down to is this: hypothetically, which patient satisfaction score do you care about the most? Is it the 22-year old with a UTI who got her Macrobid in 20 minutes or the woman whose 41-year-old husband is now dead? And why is this? Because he initially signed in as a “cough.” If a triage nurse had been able to identify the true complaint, she would have discovered he had chest pain. This wasn't translated correctly to the registration personnel, and it delayed the EKG and trip to the cath lab while the patient waited in an “expedited hall spot.” But the UTI got her Macrobid and a few Percocet so at least she will be happy and rate her experience a 5/5.

Martha Roberts, ACNP, CEN

Arlington, VA

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