The document proposes implementing a new triage system called the Comprehensive Triage Acuity System at a VA walk-in clinic to improve patient flow and outcomes. The system uses a 5-level scale to assess physical, social, and health needs and prioritize patients needing emergent, urgent, or non-urgent care. All clinic staff will receive training. The proposal aims to compare utilization rates and homeless veteran numbers before and after implementation to evaluate the system's effects.

1. The Comprehensive Triage Acuity System to Improve Patient Outcomes in a Walk in Clinic
Naomi Farkas, Lauren Hopkin, Michelle Lew, Elin Mogollon, Yaakov Perlstein, Nicole Reeger
Pace University, College of Health Professions, Lienhard School of Nursing
The names and addresses of the associated institutions go here.
Will implementing the use of the Comprehensive Triage Acuity System by
triage nurses in the Veterans Affairs New York Harbor Healthcare System
walk-in clinic, improve patient flow and decrease the number of homeless
veterans as compared to the absence of a triage protocol?
Background
EBP Recommendations
Evaluation & Conclusion
Implementation
• Develop the Comprehensive Triage Acuity System which is a five-level triage scale that
assesses physical, social, and physiological health needs. This scale is adapted from the
ESI triage system and a triage system developed by The National Health Care for the
Homelessness Council (CITE).
• This triage system will be implemented for use by all triage nurses who are completing the
initial assessment at the the Veterans Affairs New York Harbor Healthcare System walk-in-
clinic.
• The triage system delineates those patients requiring emergent care, urgent care, and non-
urgent care and the identification of homelessness.
• All staff in the walk-in-clinic will receive education sessions on the proper use of the
Comprehensive Triage Acuity System. RNs will require competency.
• An easy-to-read visual flow chart of the Comprehensive Triage Acuity System will be posted
in the triage areas of the walk-in-clinic for quick reference.
Search Strategy
References
Literature Review
• Compare utilization rates for various services provided at the VA from 2014 as baseline and
quarterly after the implementation of the Comprehensive Triage Acuity System to measure
patient flow
• Quarterly measure the number of homeless veterans in the VA system and compare with 2014
as baseline.
• A paired t-test will measure significance of implementation of the Comprehensive Triage Acuity
System
• Implementing the Comprehensive Triage Acuity System will 1) decrease patient wait time and
improve patient flow and outcomes and 2) reduce the number of homeless veterans.
• If successful, this triage assessment tool can be implemented in all VA primary walk- in clinics
throughout the nation.
Emergency Severity Index (ESI) (McHugh, Tanabe, McClelland et al., 2012).
•The ESI is the most commonly used triage system in the United States.
•Acuity judgments are addressed first based on stability of vital functions or high-risk
presentation.
•For “stable” patients, the experienced triage nurse uses the ESI to predict the resources needed
to move the patient to an appropriate disposition from the ED (admission, discharge or transfer).
U.S. Department of Veteran Affairs
•The Homeless Screening Clinical Reminder (HSCR) is a universal, two-question screener for
current homelessness and imminent risk and is preformed annually at VA healthcare facilities
(Fargo, Byrne, Montgomery et al., 2014).
•Homeless Veteran Patient Aligned Care Teams (HPACT) use a multidisciplinary approach to
address the chronic medical, mental, and behavioral health conditions among Veterans
experiencing housing instability (Fargo, Byrne, Montgomery et al., 2014).
• Veterans comprise 12% of the adult homeless population and report an average of 5.77 years vs.
3.92 years of homeless compared to non-veterans (National Coalition for Homeless Veterans,
2015) (National Survey of Homeless Veterans in 100,000 Homes Campaign Communities, 2011).
• The 1.5 million Americans that experience homelessness per year are amongst the highest users
of costly hospital based acute care (Burns, 2014).
• Emergency department (ED) crowding has been recognized as a growing problem. From 1995
through 2005, the annual number of ED visits in the United States increased nearly 20%, from
96.5 million to 115.3 million (Wiler, Gentle, Halfpenny, Heins, Mehrotra, Mikhail, & Fite, 2009).
• The walk-in clinic at the VA was established to alleviate high influx of patients in the ED; however,
there is no standardized leveled triage tool in place
College of
Health
Professions
LIENHARD SCHOOL
OF NURSING
PICO Question
Burns J. (2014). Do we overspend on health care, underspend on social needs? Manag Care, (9), 26-31. PMID: 25282862 [Evidence Level 6]
Elias, P., Damle, A., Casale, M., Branson, K., Churi, C., Komatireddy, R., & Feramisco, J. (2015). A web-based tool for patient triage in emergency
department settings: Validation using the emergency severity index. JMIR Med Inform, 3(2). doi:10.2196/medinform.3508 [Evidence
Level 6]
Gilboy, N., Tanabe, T., Travers, D., & Rosenau, A.M. (2012). Emergency severity index (ESI): A triage tool for emergency department care,
Version 4. Implementation Handbook Retrieved from http://www.ahrq.gov//professionalssystems/hospital/esi/esihandbk.pdf [Evidence
Level 7]
Gulwadi, G. B., Joseph, A., & Keller, A. B. (2009). Exploring the impact of the physical environment on patient outcomes in ambulatory care
settings. Health Environments Research & Design Journal, 2(2), 21-41. doi: 10.1177/193758670900200203 [Evidence Level 5]
Fargo, J., Byrne T., Montgomery, A. E., & Roberts, C. B. (2014). Universal screening for homelessness and risk among veterans: Monitoring
housing stability and exploring profiles of risk through repeated screening. VA National Center on Homelessness Among Veterans.
Retrieved from
http://www.endveteranhomelessness.org/sites/default/files/research/UniversalScreeningforHomelessness%26RiskAmong%20Veterans.p
df [Evidence Level 5]
Lidal, I. B., Holte H. H., & Vist, G. E. (2013). Triage systems for pre-hospital emergency medical services - a systematic review. Scandinavian
Journal of Trauma, Resuscitation and Emergency Medicine, 21(28). doi:10.1186/1757-7241-21-28. [Evidence Level 1]
National Coalition for Homeless Veterans. (2015). Background & Statistics. Retrieved from
http://nchv.org/index.php/news/media/background_and_statistics/ [Evidence Level 7]
National Health Care for the Homeless Council. (2015). Triage Guidelines. Retrieved from http://www.nhchc.org/wp-
content/uploads/2011/10/TriageGuielines_1995.pdf [Evidence Level 7]
PubMed, CINAHL, PSYCHinfo, and Up to Date databases were used to find relevant studies. The
following keywords were used: triage tool, urgent care, walk-in-clinic, assessing emergency room
patients, homelessness, and veterans. Original research articles, articles with keywords present in the
abstract or the title, articles published between 2009 and 2015 were used. Eight publications including
1 systematic review and 1 clinical guideline met the inclusion criteria.
The Comprehensive Triage Acuity System
The most common triage systems used throughout emergency rooms are the Australian Triage Scale
(ATS), the Manchester Triage Scale (MTS), the Canadian Emergency Department Triage and Acuity
Scale (CTAS), and the Emergency Severity Index (ESI) (Lidal, Holte & Vist, 2013). Evidence supports
the use of five level triage scales to effectively and efficiently manage the flow of patient care, improve
the initial assessment of patients, manage resources in the acute care setting, and to increase the
accuracy of prioritizing patient care (Lidal, Holte & Vist, 2013). Errors in the initial clinical evaluation of
patients can potentially lead to severe consequences such as a misdiagnosis, delayed treatment,
disproportionate health care resource utilization, and increased costs (Elias et al., 2015). Triage tools
have been instituted in many emergency rooms to decrease these errors (Elias et al., 2015). A
systematic review on the use of triage tools in the pre-hospital selling, such as a walk-in-clinic
determined there is insufficient research on the use of triage tools in these settings.