Triage tool in ED

2014-06-13JNUH dep. of EMSung Wook Song

Introduction• ED Challenges

– Overcrowding– Space constraints– Nursing and physician shortage– Increasing non-urgent patient volumes in the ED– Decreasing reimbursement

• Triage methods through the ages– Three-tier– Five-tier

• Emergency Severity Index (ESI) Triage– Agency for Healthcare Quality Improvement

“input” “throughput” “output” model for ED pts flow

A conceptual model of emergency department crowding. Asplin BR, Magid DJ, Rhodes KV, et al. Ann Emerg Med 2003;42:173– 80.

Causes

1. Increased complexity and acuity of patients presenting to the ED2. Overall increase in patient volume3. Managed care problems4. Lack of beds for patients admitted to the hospital5. Avoiding inpatient hospital admission by “intensive therapy” in the ED6. Delays in service provided by radiology, laboratory, and ancillary services7. Shortage of nursing staff8. Shortage of administrative/clerical support staff9. Shortage of on-call specialty consultants or lack of availability10. Shortage of physical plant space within the ED11. Problems with language and cultural barriers12. Shortage of house staff who rotate through teaching hospital EDs13. Increased medical record documentation requirements.14. Difficulty in arranging follow-up care

Effects

1. Public safety at risk2. Prolonged pain and suffering3. Long waits and dissatisfaction of patients4. Ambulance diversions5. Decreased physician productivity6. Violence7. Negative effect on teaching missions in academic medical centers8. Miscommunication because of increased volume

Solutions

1. Providing both insured and uninsured patients with better access to clinics2. Expanding inpatient hospital bed capabilities, especially telemetry, and ICU3. Development of ED observational units4. Expansion of emergency physician, nursing, and ancillary staff5. Expansion of ED square footage and bed space6. Improved support by radiology, laboratory, and consultant services7. Reduction of incoming transfers to the ED during busy periods

Ann Emerg Med 35:1, Jan, 2000: Overcrowding in the Nation’s Emergency Department: Complex Causes & Disturbing Effects

Gaining capacity

• Build a larger ED– Cost - $$$$– Space– 5-10 year plan – predictions fall short

• Decrease throughput– Turnover rooms with greater frequency– No added cost– Decreased walk-out rates – increased revenue– Improved patient satisfaction– Increased capacity

Impact of throughput times on ED capacity

ED FlowInput Throughput Output

Emergency CareSeriously ill from the community and referral sources

Unscheduled Urgent CareLack of available ambulatory careDesire for immediate care

Safety Net CareVulnerable populationsAccess barrier

Demand for ED care

Ambulance diversions

Patient arrives to ED

Triage and room placement

Diagnostic evaluation and

treatment

ED boarding of inpatients

Ambulatory Care System

Transfer to outside facility

Admit to hospital

Left without being seen

Patient Disposition

Lack of access to follow-up care

Lack of available staffed inpatient beds

COURTESY ACEP

ED Overcrowding!Input Throughput Output

Emergency CareSeriously ill from the community and referral sources

Unscheduled Urgent CareLack of available ambulatory careDesire for immediate care

Safety Net CareVulnerable populationsAccess barrier

Demand for ED care

Ambulance diversions

Patient arrives to ED

Triage and room placement

Diagnostic evaluation and

treatment

ED boarding of inpatients

Ambulatory Care System

Transfer to outside facility

Admit to hospital

Left without being seen

Patient Disposition

Lack of access to follow-up care

Lack of available staffed inpatient beds

COURTESY ACEP

The Need to PrioritizeInput Throughput Output

Emergency CareSeriously ill from the community and referral sources

Unscheduled Urgent CareLack of available ambulatory careDesire for immediate care

Safety Net CareVulnerable populationsAccess barrier

Demand for ED care

Ambulance diversions

Patient arrives to ED

Diagnostic evaluation and

treatment

ED boarding of inpatients

Ambulatory Care System

Transfer to outside facility

Admit to hospital

Left without being seen

Patient Disposition

Lack of access to follow-up care

Lack of available staffed inpatient beds

COURTESY ACEP

Triage and Room Placement

Triage

• French verb “trier” - to separate, sort, sift or select• Prioritization of patients based on the severity of illness/ injury

Food for thought

• Ultimate Goal– Get the patient to a doctor

• Is triage (sorting) necessary if there is a bed, a doctor and resources available and no wait?

• Is a nurse assessment essential for ALL patients?

The History of Triage

History

• Napoleonic Wars (early 1800’s)– Battlefield Triage– Likely to live, regardless of care– Likely to Die, regardless of care– Immediate care would make a positive difference

• Evolution over time– Pre-hospital triage– Mass Casualty triage– Managing ED inflow– Telephone triage/ medical advice lines

Introduction of Triage to U.S.A

• 1950’s• Office-based practice• After hours primary care to ED’s• Increase in low acuity use of ED’s• Overcrowding• Need to sort sick from non sick• Military physicians and nurses introduce

triage

Maturation

• Traffic Director– Non-clinical person assessing arrivals and directing to appropriate areas

• Spot check– Realization that non-clinicians are inadequate to assess patients– Used in low volume ED’s– Clerk watches ED entrance and pages the triage RN when needed

• Comprehensive – Experienced nurses– Rapidly gather “sufficient” information to determine acuity– Within a 2 to 5 minute time frame – in reality this goal is met 22% of the

time

Comprehensive Triage• Takes longer to triage “extremes” of age

• Definite benefits– Each patient is greeted by an experienced nurse– A sick patient is immediately identified– First aid is provided as needed– The nurse is available to meet the emotional needs of

the patients and families in the waiting room

Triage Nurse Triage nurses require advanced clinical decision

making expertise

• They need to – Make complex clinical decisions, in conditions of

uncertainty with limited or obscure information, in minimal time

– Have limited margin for error– Be able to rapidly identify and respond to actual life-

threatening states– Be able to make a judgment on the potential for life-

threatening deterioration

Triage Nurse

ED Triage Goals– To sort a group of patients who present simultaneously

to the ED– To ensure

• Appropriate care• Appropriate location• Appropriate degree of urgency

– To initiate care in response to clinical need rather than order of arrival

– To promote safety by ensuring that timing of care and allocation of resources matches the degree of illness or injury

Triage Outcomes• Expected triage – triaged appropriately

– Seen by a doctor within a suitable time frame and should have a positive health outcome

• Over triage – triaged to a higher level then indicated– This decreases the wait time for the patient, which is not detrimental to the

patient, however the inappropriate allocation of resources has the potential to adversely affect other patients

• Under triage – triaged to a lower level then indicated– This prolongs the wait time until medical intervention and there is potential

for deterioration or prolongation of pain and suffering. These factors increase the risk of an adverse patient outcome

USA Triage Protocols• Maclean: 2001 survey of 27% of all ED’s in the

United States– 69% used 3-Tier Triage– 12% used 4-TierTriage– 3% used the Australian or Canadian 5-Tier Triage– 16% did not use a scale or did not answer

• National Center Health Statistics: 2003– 47% used 3-Tier Triage– 20% 4-Tier Triage– 20% 5-Tier

3-Tier• Levels

– Emergent: Poses an immediate threat to life or limb– Urgent: Requiring prompt care, but can wait “hours”– Non-Urgent: Condition needs attention, but time is not a critical

factor

• Large variation in definition for each level by hospital• No clear correlation with disposition• Large volume of “urgent” patients – with varying degrees

of illness

Reliability of 3-Tier Triage

• Wuerz, Fernandes, Alarcon – 1998– Triage nurses and EMT’s at 2 hospitals– Rated the acuity of 5 scripted patient scenarios using

3-tier scale– Same people repeated the triage assignment 6 weeks

later– Only 24% rated all 5 cases the same in both phases– Overall kappa (inter-observer variability) statistic was

0.35 (0: no agreement; 1: perfect agreement)– 3-Tier not reliable, not effective

Four-Tier Acuity Scales

• Blue – Red – Yellow – Green• Attempted to split the 3-tier “red” and “yellows”• More equitable distribution of patients across the

levels• Requires a high degree of nursing experience to

do accurately• Poor reliability and reproducibility

Five-Tier Triage• Australasian National Triage Scale – 1994

“This patient should wait for medical assessment and treatment no longer than ____ minutes”

• Correlates strongly with – Resource consumption– Admission rates– ED length of stay– Mortality rates

• Used as a basis of ED assessment and quality of care – patients need to be seen within the triage assigned time

Quality Goals

ATS Category Description Time to Doctor Compliance Goal

ATS 1 Resuscitation Immediate 100%

ATS 2 Emergency 10 minutes 80%

ATS 3 Urgent 30 minutes 75%

ATS 4 Semi-Urgent 60 minutes 70%

ATS 5 Nonurgent 120 minutes 70%

Manchester Triage – 1997• Ascertain patients chief complaint• Select 1 of 52 flow charts with an algorithm that assigns

a triage score of 1 to 5 based on a structured interview• Reliability study comparing nurse triage to senior

medical staff triage– Fair to Moderate reliability

• Time to doctor– 1 Immediate 0 minutes– 2 Very Urgent 10 minutes– 3 Urgent 60 minutes– 4 Standard 120 minutes– 5 Nonurgent 240 minutes

Canadian Triage and Acuity Scale (1996)

• Pediatric Modifications• Initial impression of severity of illness• Evaluation of presenting complaint• Assessment of behavior and age related physiological

parameters• Limited assessment for assigning Level 1 or 2• Full assessment for 3,4,5• Quality goal: to see a high percentage of patients in each

category in the specified time

Time factors

• Used for quality• Allows acuity adjusted comparison of ED’s• Used for predicting staffing models for physicians and staff

Table 1: Suggested time goals, fractile response rates and admission rates by triage level

TRIAGE LEVEL

I II III IV V

Time to care Immediate 15 mins 30 mins 60 mins 120 mins

Fractile Response

98% 95% 90% 85% 80%

Admission Rates

70%-90% 40%-70% 20%-40% 10%-20% 0%-10%

Outcomes• Strong correlation for admissions• Inter-rater reliability high

– Physician and RN: Kappa 0.85– Physician, RN and Paramedic: Kappa 0.77

• Used by paramedics for pre-hospital triage• Used for staffing predictions

– Time spent by physician for each triage level

• Used for evaluating practice variability• Is a country-wide measure of timeliness of service

The Emergency Severity Index

• Wuerz and Eitel – 1998• Fundamentally the closest to when triage originated• Principal goal of triage is to facilitate prioritization of patients based on

the urgency of the condition– Which person is seen first– How many resources will they require

• Patient sorting + patient streaming• Underlying assumptions of the 1st 3 5-tier systems was “how long can

the patients wait • There is no time allocation in ESI• Dying patient - see immediately• Sick appearing patient- “shouldn’t wait”• The lower 3 levels are categorized based on resource needs

1

2

3

45

no

no

no

yes

yes

abnormal

Decision Point A• Is the patient dying

•Needs an immediate airway, medication, or other hemodynamic intervention•Is already intubated, apneic, pulseless, severe respiratory distress, SpO2 < 90 percent, acute mental status changes, or unresponsive

Decision Point B

• Should the patient wait?

• Is this a high-risk situation?• Is the patient confused, lethargic or disoriented?• Is the patient in severe pain or distress?

Decision Point C• Resource Needs

•To identify resource needs, the nurse needs to be familiar with ED standards of care – EXPERIENCE!

Decision Point D• The Patient’s Vital Signs

•If out of range upgrade 3 to 4

Decision Point: Pediatric Fever• Fever

•Recommendation: Check temp <3 years at triage

Five-Tier Acuity Rating Scales• Widespread use of ESI in the United States• Canadian and US nurses studied together – randomized to

ESI and CTS– Kappa for ESI 0.89– Kappa for CTS 0.91

• Advantages• Easy to learn and implement• High degree of inter-rater reproducibility and reliability

– Kappa 0.88• Ability to predict hospitalization, resource utilization, ED length of

stay and six-month mortality• Moderate correlation with physician E/M codes and nursing

workload• Facilitates meaningful comparison of case mix between hospitals

http://www.esitriage.org