Is triage the baby or the bathwater when it comes to ED flow?
Triage as a system of managing patient flow in the emergency department seems to be under attack. For instance, Dr. Shawn Whatley, a colleague of mine in Ontario, recently published the book No More Lethal Waits, which criticizes the current approach to triage and has received a fair bit of media attention. The first step Dr. Whatley proposes to improve ED access is to “revamp triage” and “close the waiting room.” Also, in 2015, Dr. Rick Bukata, a well-known American emergency physician and educator, wrote an article titled: “Has triage become an intrusive waste of time?” Dr. Bukata’s question was rhetorical; his answer was a firm “yes.”
Are these ED physicians right? Is triage obsolete? I will explore the parts I think they have right and where they and others go wrong in this blog.
History and the Development of Triage
Traditionally, triage at entry to the ED has been seen as a strategy to deal with crowding and delays; “triage,” which means “to sort,” reportedly dates to the Napoleonic era and was used to decide which soldiers who had been injured in battle were to be seen first and who could wait (including those too injured to be saved). Triage has at times been considered an advanced clinical skill based on experience—in mass casualty situations, the senior surgeon is often selected as the triage officer—while at other times it’s been relegated to clerical staff or volunteers on the assumption that anyone with common sense can tell at a glance who is a victim of a gunshot and requires urgent care, and who has a minor cough and can safely wait longer to be seen.
Two parallel trends in ED care have developed over the past 20 to 30 years, and where they converge we sometimes find a result that has led to suggestions that triage is broken. The first trend has been to make triage more rigorous; the second has been to expand on the opportunity provided at initial assessment by adding broader patient screening and assessments.
With respect to adding rigour, several triage systems have been developed and tested; Canada’s five-level Canadian Triage and Acuity Scale (CTAS) system is arguably the best and most validated of these, and it is now used in many countries around the world.1,2,3,4,5
Meanwhile, some hospitals have been adding to the triage assessment. For instance, infection control concerns and contagious outbreaks, including SARS, have led to the inclusion of screening for infectious diseases at reception/triage. Patients who fail screening are moved to isolation for further assessment. As well, some EDs have included extended nursing assessments at triage, including medication listing or full reconciliation, allergy screening, and a review of past medical history. Some have advocated adding broad screening for domestic violence and suicidal thinking, and in the elderly screening for dementia, depression, and delirium. Some EDs use medical directives to start interventions at triage from diagnostics (blood draws, ECGs, even imaging orders) to therapeutics (start I.V.s, administer fever or pain meds). At times, these activities can create the spectre of a lineup of patients waiting to be triaged while care spaces are available and staff are waiting to see the next patient. In these circumstances, triage seems to be a bottleneck, or even a waste of time. Is it? What is the solution?
Is triage obsolete?
First, let’s consider the contention that triage is no longer necessary—where we have achieved near-zero waiting. EDs are dynamic places, and I don’t think any ED anywhere has truly achieved zero waiting 100% of the time. The longer the wait to be seen, the greater the risk to the patient, and therefore the more important accurate triage becomes. But in one example, the generally accepted target for door-to-ECG time in a chest pain patient is 10 minutes; I don’t think we can pick out all the chest pain patients at a glance, so without triage you will not meet the ECG target time. In any real-world situation, even in the best-performing EDs, some triage will occur. In Ontario, where Dr. Whatley and I practise, despite eight years of co-ordinated policy efforts to improve access, the overall average time from arrival to seeing a physician is about 90 minutes, so waiting will not disappear here anytime soon.
If some sorting or triaging is happening, then who should do it, and how? At the start of my career it was common for the registration staff to greet patients and, with no real training, send some patients to the nurse and continue to register others. But in 1999 in Ontario, the inquest sparked by the case of a young boy who died of sepsis found that he’d been “triaged” by a volunteer and had not seen a nurse or other professional until his mother raised an alarm in the waiting room three hours after arrival. Ontario then mandated that all patients be triaged using CTAS by a registered nurse within 15 minutes of arrival.
Initial assessment could be done by a non-professional informally, or by a nurse or other professional using a standardized approach. Given the stakes, and our experience in Ontario with mandated nurse triage for almost 20 years, I want my department using nurses to triage. But isn’t standardized triage too rigid, and doesn’t it take too long? CTAS has been evaluated for its reliability and validity, and the time taken to triage using CTAS has been tested in several countries.6,7 Very ill/unstable patients should be recognized and taken into the department immediately, and can be assigned a CTAS score of 1—no delay there. Other patients will take no more than two to five minutes to be assessed and given a CTAS score.
Furthermore, triage today doesn’t just determine the order in which patients will be seen. Most busy EDs will use the triage assessment to determine where to see the patient, whether in a “fast track” or Rapid Assessment Zone (RAZ; intermediate-acuity areas where patients access stretchers when necessary and wait in a chair at other times) or in the major areas.
Many quality improvement programs also have key interventions triggered by triage recognition. I mentioned the ECG in chest pain, but how about a suicidal patient sitting quietly waiting her turn? A triage assessment should trigger constant observation protocols immediately. Febrile patients meeting SIRS criteria should receive a sepsis “bundle,” and a patient with a thunderclap headache needs his brain CT arranged quickly to avoid a lumbar puncture where possible (for instance by a triage nurse asking an MD for a verbal order or quick assessment).
All of the above makes the case that the critical need to orderly sort incoming patients, direct them to the proper zone for assessment, and initiate key interventions all benefit from a structured, evidence-based approach by a health professional. This should not create a bottleneck if triage guidelines are being properly applied and the hospital has staffed the triage area adequately.
“The critical need to orderly sort incoming patients, direct them to the proper zone for assessment, and initiate key interventions all benefit from a structured, evidence-based approach.”
Keep triage—but make it better
What else, if anything, must be done at triage if we want to avoid a bottleneck? Identifying and isolating patients who represent a contagious risk is best done as early as possible and need not take long. No cough, no fever, done!
The rest of the activities sometimes done at triage, from medication reconciliation to health equity questions, can be done at the primary nursing assessment once the patient is settled in a care space. I believe at times these things have ended up being done during triage because of interpersonal pressures between nurses or other factors that are likely provider centred rather than because a careful analysis showed this was the best place to perform these tasks. Each ED can decide what activities they are going to do and where they will do them, but the decisions should be based on an objective assessment of the impact on quality and flow, as well as patient experience.
If we call triage that is combined with several of the deferrable screening assessments and interventions sometimes also done on arrival “triage PLUS,” then I agree, “triage PLUS” can be a bottleneck. But if dialling things all the way back to informal triage is not the solution, what is the best approach?
Nurses who are properly trained in structured triage should be fast and flexible at applying it. Properly managed EDs will have adequate staff at triage to cope with normal arrival patterns and a plan to respond to a sudden surge or a growing queue. Infection control screening should also be applied quickly. When treatment spaces or internal waiting areas are available, patients should be moved quickly from triage into the ED. Having a plan for how to get those ECGs in 10 minutes, initiate a patient watch where needed, and order time-sensitive tests such as head CTs quickly all must be part of the triage and subsequent immediate response.
When the ED experiences access block, we shouldn’t waste the time patients spend waiting. Nurses armed with medical directives should be initiating a broader range of interventions in the waiting room, and/or doctors should be coming out to triage to see patients as they wait for formal treatment spaces to become available. Having the triage nurse able to provide an ice pack, oral analgesics, or antipyretics can go a long way to communicating that we care. If “triage PLUS” is the rigid application of the full menu of items described above, then a slimmed down, flexible triage and infection control screen, paired with carefully deployed initial interventions attuned to department circumstances, is what I will call “triage RIGHT.”
We can also support nurses in their learning and application of triage. Electronic decision support tools have shown they can be applied in the same amount of time as memory/paper-based triage and will enhance reliability and produce a digital triage record.6,7 In fact, my home province of Ontario has invested $5 million in the province-wide implementation of an electronic triage tool. The tool is in development, but the early impression from nurses in the field is very enthusiastic.
What about registration?
So far, I have not discussed the registration process. Although registration can feel very bureaucratic, getting the patient identified properly, making sure we have the right contact information (who hasn’t had their heart sink when calling a patient back for a positive blood culture, only to find the contact information is incorrect?), and getting labels and arm bands right are really part of the safety mechanisms of care. Triage should always precede registration, however, and registration should be optimized by being flexible and using the latest technology (kiosks, tablets, card readers etc.).
I think “triage PLUS” as I have defined it is a problem, and I applaud Drs. Bukata, Whatley, and others who have called it out and say it is not patient centred. But they confuse “triage PLUS”—a rigid monster—with the proper, flexible, and efficient “triage RIGHT.” I think “triage PLUS” is the bathwater, and it can go; but let’s keep the triage baby!
Dr. Helman and Dr. Ovens have no conflicts of interest to declare.
References for Is Triage Obsolete?
- Bullard MJ, Chan T, Brayman C, Warren D, Musgrave E, Unger B. Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) Guidelines. Can J Emerg Med. 2014:1-5. doi:10.2310/8000.2014.012014.
- Jimenez JG, Murray MJ, Beveridge R, et al. Implementation of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the Principality of Andorra: Can triage parameters serve as emergency department quality indicators? Can J Emerg Med. 2003;5(5):315-322.
- Ng C-J, Yen Z-S, Tsai JC-H, et al. Validation of the Taiwan triage and acuity scale: a new computerised five-level triage system. Emerg Med J. 2011;28(12):1026-1031. doi:10.1136/emj.2010.094185.
- Hamamoto J, Yamase H, Yamase Y. Impacts of the introduction of a triage system in Japan: a time series study. Int Emerg Nurs. 2014;22(3):153-158. doi:10.1016/j.ienj.2013.10.006.
- Elkum NB, Barrett C, Al-Omran H. Canadian Emergency Department Triage and Acuity Scale: implementation in a tertiary care center in Saudi Arabia. BMC Emerg Med. 2011;11(1):3. doi:10.1186/1471-227X-11-3.
- Bullard MJ, Meurer DP, Pratt S, Colman L, Holroyd BR, Rowe BH. Evaluation of Triage Nurse Satisfaction with Training and Use of an Electronic Triage Tool [Abstract]. Acad Emerg Med. 2003;10(5):538. doi:10.1197/aemj.10.5.538-a.
- Levin S, France D, Mayberry RS, Stonemetz S, Jones I, Aronsky D. The Effects of Computerized Triage on Nurse Work Behavior. AMIA Annu Symp Proc. 2006:1005. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1839482&tool=pmcentrez&rendertype=abstract.
Thanks to Kirby Ding, University of Toronto Medicine 2018 for his assistance with a literature search on CTAS.