2014-06-13 Emergeny dep. , JNUH Sung Wook, Song

1. Triage tool in ED
2014-06-13
JNUH dep. of EM
Sung Wook Song

2. 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

3. “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.

4. Causes
1. Increased complexity and acuity of patients presenting to the ED
2. Overall increase in patient volume
3. Managed care problems
4. Lack of beds for patients admitted to the hospital
5. Avoiding inpatient hospital admission by “intensive therapy” in the ED
6. Delays in service provided by radiology, laboratory, and ancillary services
7. Shortage of nursing staff
8. Shortage of administrative/clerical support staff
9. Shortage of on-call specialty consultants or lack of availability
10. Shortage of physical plant space within the ED
11. Problems with language and cultural barriers
12. Shortage of house staff who rotate through teaching hospital EDs
13. Increased medical record documentation requirements.
14. Difficulty in arranging follow-up care
Effects
1. Public safety at risk
2. Prolonged pain and suffering
3. Long waits and dissatisfaction of patients
4. Ambulance diversions
5. Decreased physician productivity
6. Violence
7. Negative effect on teaching missions in academic medical centers
8. Miscommunication because of increased volume
Solutions
1. Providing both insured and uninsured patients with better access to clinics
2. Expanding inpatient hospital bed capabilities, especially telemetry, and ICU
3. Development of ED observational units
4. Expansion of emergency physician, nursing, and ancillary staff
5. Expansion of ED square footage and bed space
6. Improved support by radiology, laboratory, and consultant services
7. 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 Ef

5. 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

6. Impact of throughput times
on ED capacity

7. ED Flow
Input Throughput Output
Emergency Care
Seriously ill from
the community and
referral sources
Unscheduled
Urgent Care
Lack of available
ambulatory care
Desire for
immediate care
Safety Net Care
Vulnerable
populations
Access 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

8. ED Overcrowding!
Input Throughput Output
Emergency Care
Seriously ill from
the community and
referral sources
Unscheduled
Urgent Care
Lack of available
ambulatory care
Desire for
immediate care
Safety Net Care
Vulnerable
populations
Access 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

9. The Need to Prioritize
Input Throughput Output
Emergency Care
Seriously ill from
the community and
referral sources
Unscheduled
Urgent Care
Lack of available
ambulatory care
Desire for
immediate care
Safety Net Care
Vulnerable
populations
Access 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 and Room
Placement

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

11. 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?

12. The History of Triage

13. 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

14. 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

15. 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

16. 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

17. 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

18. Triage Nurse

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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%

27. 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

29. 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

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

31. 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%

32. 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

33. 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

35. 11
22
33
4455
no
no
no
yes
yes
abnormal

36. 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

37. 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?

38. Decision Point C
• Resource Needs
•To identify resource needs, the nurse
needs to be familiar with ED standards
of care – EXPERIENCE!

39. Decision Point D
• The Patient’s Vital Signs
•If out of range upgrade 3 to 4

40. Decision Point: Pediatric Fever
• Fever
•Recommendation: Check temp <3 years at triage

41. 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

43. http://www.esitriage.org