Triage is a system of clinical risk management used in urgent care settings (Emergency Departments (EDs), walk-in centres, minor injury units, general practice) where an undifferentiated and unexpected caseload arrives at a point of care. It is used worldwide to manage the patient flow through these areas safely, when need exceeds the capacity of the service and its aim is to sort patients according to clinical urgency (van der Linden et al. 2012). This chapter will focus on the development of triage roles, types and systems.
The word triage originates from the French verb ‘trier’, meaning ‘to sort’. The origins of triage are well documented and it was originally used as a means of grading the quality of goods such as coffee beans and wool, and was first adopted for use in a medical context during the Napoleonic wars (Bracken 2003). For the first time, casualties were treated on the basis of medical need rather than rank or social status although at this time, those treated first were those who needed minimal attention in order that they could return to the battlefield. Triage, in the form we recognize now, where the most injured are dealt with first, emerged rather later in the Korean War. It has been used in every war since, as a means of managing mass casualties. While the term triage is used in both military/disaster triage and EDs, it must be recognized that the two processes fulfil very different functions.
Peacetime nursing triage emerged in the US in the early 1960s during the war in Korea. Highly trained paramedics moved across into civilian hospitals, taking their triage skills with them and adapting the process for use within EDs. It was not until the 1980s that the concept of nurse triage became popular in the UK. EDs began introducing schemes around this time, based largely on the experiences of American nursing colleagues.
The unpredictability of workloads within emergency settings and the steadily increasing numbers of attenders are well recognized and documented (Mallet & Woolwich 1990, National Audit Office 2004, Department of Health 2010). During a 24-hour period a wide spectrum of accidents and emergencies may be seen, sometimes stretching the resources of the department and staff to their limit. Walk-in centres and NHS Direct have not been demonstrated to reduce attendance in EDs (Cooke 2005).
Prior to nurse triage, the waiting room was an unknown quantity for the ED staff. It could be full of patients with a diverse range of illnesses and injuries, of varying degrees of severity and without any screening there was a risk of a patient’s condition deteriorating while waiting to be seen. It is inevitable that with the ever-increasing demands on a finite service, longer waiting times develop and the most vulnerable group of patients, i.e., those who are seriously ill and in need of immediate emergency care and treatment, may not be identified and prioritized. Recognition of all these factors highlights the need for all patients to be assessed on arrival in the ED by a person skilled in triage.
The purpose of triage in the emergency care setting is not to reduce the overall waiting time for all patients. Mallet & Woolwich (1990) have shown, in line with other studies, that while the waiting times for the more seriously ill were reduced, overall departmental waiting times steadily increased. The purpose of triage is to ‘make the best possible use of the available medical and nursing personnel and facilities’ and it is there to assist in determining ‘which patients need immediate care … and which patients can wait’ (Potter 1985).
In a joint statement, the College of Emergency Medicine, the Emergency Nurse Consultants Association, the Faculty of Emergency Nursing and the Royal College of Nursing Emergency Care Association (2011) defined triage as ‘a complex decision making process to manage clinical risk’. Therefore, the primary aim of the triage nurse must be the early assessment of patients, in order to determine the priority of care according to the individual’s clinical need. There are other aspects of care, however, that nurse triage can meet (Handyside 1996), for instance, more efficient use of the department facilities and resources as patients are allocated to the most appropriate clinical areas within the department and are seen and treated within an appropriate time. As triage should be a dynamic process, regular reassessment of patients ensures that the appropriateness of the care implemented can be modified as necessary.
The early and appropriate requesting of medical records or relevant previous X-rays will aid clinical assessment and diagnosis. Appropriate first-aid measures can be taken without delay and analgesia appropriate to the patient’s level of pain can be given.
The waiting area is now a known quantity and patient flow can be controlled and organized. Patients and their relatives have an easily identifiable and reliable source of information for any enquiries. This helps to relieve anxiety and reduce aggression and can increase patient satisfaction with the service (Dolan 1998).
Patients arrive in the ED, register with the receptionist and then sit in the waiting area, without any form of assessment, until they are called to be seen by the clinician. The receptionist will only call a clinician if there appears to be some reason for concern.
In the UK, non-professional triage can still be found functioning in some departments and is more frequently used at certain times, e.g., at night when staff and resources are limited. Mallet & Woolwich (1990) identified this as an area of great concern in their study of nurse triage in an inner-city ED and recommended the provision of a nurse triage service during the night shift. Their concerns are echoed in the findings of a large study of the use of health care assistants (HCAs) in English EDs, which found that HCAs assessed patients on arrival in 28.7 % of the 282 departments that responded to the survey (Boyes 1995).
Triage tends to have been recognized as a system which must be undertaken by a competent clinician; however, there are a number of emergency care settings where non-professional triage may be, while not the system of choice, the system which has to be lived with. Walk-in centres and minor injury units may not have levels of professional staff in which a qualified nurse can be allocated to a triage role. Nurses undertaking advanced practice roles are likely to be dealing with existing patients, away from the waiting area and therefore are not aware of the clinical need of those patients walking into the department.
Similarly, in general practice, the receptionist is always the first point of contact for the patient and there is little chance of a clinician being present when a patient who needs urgent care walks in. In these circumstances it is imperative that reception staff have a clear set of guidelines to work from to help them to identify those patients for whom urgent professional care must be obtained. Algorithms may be developed which reception staff are able to work through and appropriate training must be given to aid reception staff to undertake this crucial role.
Triage may be undertaken by a range of professionals in emergency care settings such as nurses, medical staff, ambulance paramedics and emergency care practitioners (ECPs). What needs to be common among these clinicians is experience and education. Because triage often uses algorithms to enable reproducible decisions in the care setting, it might be felt that it could be undertaken by anyone working in the setting. The level of decision-making which takes place within the rapid triage encounter requires sound clinical judgement which must be based on professional experience, knowledge and skill. The triage practitioner must be able to interpret, discriminate and evaluate the information he gathers from the patient, relative and carer and must be able to reflect on their decision-making and critically appraise it (Mackway-Jones et al. 2005).
A major expansion of the triage process has been the recognition and development of telephone triage. As in the case of face-to-face triage, this strategy was first identified in the US (Simenson 2001).
Advice-giving over the telephone has always been a part of the clinician’s role, although not one that has been recognized as having a particularly distinct identity. Formalized advice-giving by telephone has the potential to be a valuable tool in many settings – a fact that has been recognized in the development of NHS Direct in England and Wales and NHS 24 in Scotland. Some 5 million calls were made to NHS Direct in England in 2009/10 (NHS Direct 2010).
Telephone triage was first described as a useful emergency care strategy in the UK by Buckles & Carew-McColl in 1991. Various benefits have been attributed to it, including reduced attendance due to explanations and self-care advice, redirection of patients to more appropriate agencies, pre-identification of patient problems, cost-effectiveness, in terms of reduction in workload, and patient empowerment.
Telephone triage has many difficulties. The patient is not visible, so many of the cues that experienced clinicians take from the patient’s appearance and behaviour are not available. The information may be gained from an intermediary such as a relative or neighbour or another health professional who may not know the patient well (Marsden 2000, Purc-Stephenson & Thrasher 2010).
Telephone triage must be approached as a distinct role and not undertaken by the member of staff who happens to be passing the telephone when it rings. Early studies of telephone triage suggested that patient assessment in telephone triage was, on the whole, subjective and required careful questioning which was often poor and carried out by unqualified personnel. A designated telephone triage clinician should be the first point of contact for telephone advice or triage in the emergency care setting. Decisions should be as reproducible as those made in face-to-face triage and, therefore, protocols or algorithms need to be developed. A key feature of these must be advice for the patient or carer – advice on self care if the decision is made that this is appropriate, but also advice for the patient or carer about what do to in the interim period between the call and the access to emergency care. This might include advice on basic life support while the ambulance service is directed to the caller.
The demarcation line between telephone advice and telephone triage is debatable. But it may be considered that triage occurs when a formalized process of decision-making takes place which allows identification of a clinical priority and allocation to predetermined categories of urgency of need for clinical evaluation and care. Many EDs and walk-in centres no longer offer telephone advice and have a direct transfer to NHS Direct or NHS 24 as appropriate.
As stated above, proponents of triage have never claimed that it reduced waiting times in the emergency care setting, merely that it acts as a risk-management tool, prioritizing services in a setting where demand often outstrips capacity. The triage encounter should be a rapid and reproducible assessment which accurately allocates a priority to each patient based on clinical need. A national triage system has been adopted in Portugal, using one of the systems most often used in the UK, the Manchester Triage System, and reports, nationally, that the triage encounter need take no more than 90 seconds (Lipley 2005).
At this initial assessment, opportunities have often been taken for clinicians to ‘add in’ other aspects of examination and investigation and the triage encounter includes much more than assessment, first aid and prioritization. It is used as a time to administer analgesia, to refer patients to X-ray or other investigations, to give advice about self-care and to initiate patient pathways to other specialties. This vastly increases the time taken to triage each patient and, whereas the triaged patients in the waiting room are a known quantity, the risk is transferred to the queue for triage. The triage assessment has become an ‘MOT’ rather than the ‘pit stop’.
The premise at the beginning of this chapter is that triage is used to prioritize resources when supply does not meet demand. Where there is sufficient capacity in the emergency care setting, it is clear that prioritization is not required. One of the developments in emergency care in the UK has been the utilization of a ‘See and Treat’ model in the ‘minor’ areas of emergency care settings.
The challenge for EDs in the UK is to provide fast, fair and convenient access to health care in all sectors. There should be minimal wait for care with the right clinicians caring for the right patients at the right time (Windle 2005) and this had been a major challenge for emergency settings. A survey of patient experiences showed that patients prioritized waiting times, especially for less severe conditions, as their main issue of concern (Cooke et al. 2002).
See and Treat is a system of ED organization where patients with minor conditions are seen very quickly after they arrive in an ED by a senior clinician. Providing their problem is appropriate, such patients are examined, have definitive treatment and are then discharged (NHS Modernisation Agency 2004). This system of care emerged from the need to deal with long waiting times in EDs experienced particularly by those with the most minor presentations.
• on arrival, patients are seen, treated and referred or discharged by one practitioner
• the first person to see the patient, usually a nurse or doctor, is able to make autonomous clinical decisions about treatment, investigations and discharge
• other, more seriously ill patients or those requiring in-depth assessment or treatment should be streamed to, and dealt with in, the appropriate area
• triage of walk-in patients is unnecessary when See and Treat is in operation and patients are seen shortly after arrival
• dedicated staff allocated to separate areas and only withdrawn in exceptional circumstances.
• the system should operate with enough people to allow effective consultations without a queue developing; for instance, one doctor and one nurse has been shown to be effective for an arrival rate of up to 10 walk-in patients per hour
• staff development should be undertaken to ensure that all staff involved in See and Treat are able to make the system work effectively (NHS Modernisation Agency 2004).
There is no doubt that streaming in the ED and the use of See and Treat models has had a major effect on patient throughput (Shrimpling 2002) and has been endorsed by both the RCN Emergency Care Association and British Association for Emergency Medicine (BAEM). However, See and Treat is not without criticism, including the problems of the most senior clinicians dealing with the least serious presentations, thus potentially leaving the small number of seriously ill or injured patients being cared for by less experienced and less well supervised staff, the burn-out or boredom of senior clinicians dealing with interminable minor problems (Leaman 2003, Windle & Mackway Jones 2003) and the lack of adequate evaluation and evidence on which to roll out such programmes (Wardrope & Driscoll 2003). Literature search reveals little evaluation of See and Treat since this date with Maull et al. (2009) stating that although their fast-track strategy significantly improved service delivery to patients with minor conditions, service for patients with more acute conditions was not proportionately improved. Overall, however, department waiting times decreased.
It is clear though that where See and Treat services work optimally, where there is little or no queue and where there are always enough clinicians to manage the patient at the point of entry, triage is not necessary.
In many EDs though, while this may be a true picture on occasion, it is not likely to be the case all the time, with high patient attendance and sub-optimal staffing being the norm in most EDs. There is no doubt that waiting time is reduced using a See and Treat model in many cases but, while waiting times may be reduced, they still exist and where there is any wait at all to be seen by a clinician the waiting room becomes an unknown quantity and clinicians are back to the situation pre-triage where there was no knowledge of who was waiting and a major clinical risk-management issue. Just because a patient walks into the ED, it cannot be assumed that his problem is minor.
In any such situation, triage is essential in order to evaluate and prioritize waiting patients and manage the clinical risk. Many departments have implemented a policy of restarting triage when the queue for See and Treat reaches a critical point. The critical point should be determined centrally, after a careful analysis of case mix and workload predictions, and may be anything from 15 to perhaps 45 minutes and beyond. The decision to take the risk of not assessing patients who walk into the department for this length of time is one of ‘acceptable’ risk and the validity of the acceptability of the risk will only be indicated by the lack of critical incidents associated with it over time. The issues around stopping and restarting triage are clear though – when the wait for See and Treat has increased, who will be made available to begin to triage patients when taking a clinician away from an area will inevitably lead to further delays? This must be balanced though against the clinical governance issues involved here, and flexibility needs to be built into streaming systems to allow them to function safely when their performance is suboptimal due to problems with workload or staffing.
See and Treat is a strategy for use with those patients with minor conditions. For those patients who do not fall into this category, triage is an essential first part of the prioritization and risk management process.
Triage, as stated earlier, should be a rapid, relatively superficial assessment taking no longer than a few minutes. Its purpose is to elicit information from the patient in order to determine their presenting problem. While in some cases this may be a quite straightforward process, e.g., a patient presenting with a clear history of simple uncomplicated trauma to an extremity, a significant proportion of attenders to the ED present with a more complex history involving various contributing factors which pre-empted their current illness or injury. It is the latter presentation that calls on the skills of the triage nurse. Diagnosis is not, and never should be, an aim or outcome of the triage encounter. Spot diagnosis, based on minimal information, may be correct when undertaken by an experienced clinician but it does not necessarily equate to priority and if incorrect, the potential for disaster is high, for both patient and clinician.
Various assessment tools have been developed which will aid the nurse in decision-making and encourage standardization of patients’ assessments and subsequent collation of information. SOAP is an assessment tool devised in the US in 1969 (Lee & Fraser 1981). An ‘I’ for ‘implementation’ has been added after SOAP and an ‘E’ to emphasize the need for continual evaluation (Blythin 1988). Blythin’s SOAPE became one of the first and most extensively used triage tools in the UK.
One of the potential problems with using this tool for the less experienced nurse is that by working systematically through the acronym, the nurse becomes caught up with the S – subjective assessment – and fails to reach the A, the actual assessment. Although S is the first letter, A and O are crucial elements of the tool. It is the objective assessment (O) which is often the best indicator of a patient’s urgency for need of care. There is a rapid absorption of data which combines with a mental comparison with previous cases as the general appearance of the patient is assimilated by the triage nurse from the moment he comes into view. Along with a triage first impression (A), the objective assessment is often the critical factor when making a triage decision. It needs to be understood that the documentation of a triage decision, using any of the assessment tools devised, is secondary to the process of making that decision.
Other assessment tools have included the mnemonic P (provocation or palliation), Q (quality of pain), R (region and radiation), S (severity), T (time/history) to assess pain (Budassi & Barber 1981). They also suggest a tool involving the use of the five senses – looking, listening, smelling, touching and thinking – to evaluate a patient’s chief complaint (see Boxes 35.1, 35.2 and 35.3).
There are many theories of decision-making and a number of strategies used in the decision-making process. Unstructured triage methods may involve the triage clinician coming to a decision about a triage category with very little structure on which to base the decision.
Symptom clustering is a method used to assist in determining the clinical need of the patient. Using existing knowledge and experience, the nurse groups together symptoms and aims to identify the severity of the patient’s condition. In this manner, ‘chest pain’ can be more easily associated with a cardiac condition if the symptom cluster includes nausea, shortness of breath on exertion, grey or clammy pallor, radiation of pain to the jaw or left arm, ‘crushing’ type pain or a ‘tight band’ across the chest. Conversely, a symptom cluster which includes increased pain on coughing and deep inspiration, shortness of breath on talking, and a productive cough would be more indicative of a respiratory or pulmonary condition.
‘Clinical portraits’ or pattern recognition is a strategy very commonly used by clinicians (Alfaro-LeFevre 2004). There are some illnesses and injuries that are so easily recognizable and that present so often in the ED that a very clear ‘clinical portrait’ can be recognized. A symptom cluster narrows the options to a recognized injury or disease process in a particular system. Clinicians interpret the information they gain from the patient and compare it with previous cases. The very fast processing of information undertaken along with years of experience of different presentations and groups of symptoms is recognizable in expert practitioners. This is a technique which develops with experience and may appear to be intuitive.
Benner’s (1984) model of skill acquisition looks at the way in which expertise in an area develops through an individual’s experience. The novice, proficient or competent practitioner tends to use conscious decision-making where the expert is able to utilize pattern recognition.
Repetitive hypothesizing is a technique also employed by clinicians to test their diagnostic reasoning. By gathering data to prove or refute a particular hypothesis, a decision can be made.
It has been suggested that if the triage categories are clear and unequivocal, the role of the triage nurse can be carried out by any nurse, novice or expert, after the minimum training (Burgess 1992). The presence of a series of signs or symptoms will inherently warrant a particular priority, usually through the adherence to a written protocol in the form of flow charts, algorithms or simply lists of conditions in pre-designated priority categories.
Expertise is needed, however, as it is the experienced practitioner who is able to differentiate, for example, between cardiac and pleuritic chest pain; who understands that not all presentations of myocardial infarction are classical; who has an evidence base that tells them that women present with MI in different ways to men and is able to use all this knowledge to accurately allocate a triage category in a very rapid manner (Benner et al. 2009).
It should be recognized that the ability to ask the ‘minimum of questions with the maximum of value’ (Rund & Rausch 1981) comes with experience in the clinical area.
A reliable system of establishing priorities of care is the linchpin that determines the effectiveness of nurse triage. There may be circumstances whereby there are few data on which to determine a priority. Poor communication due to language difficulties is not uncommon, and the age or condition of the patient may also hinder the triage nurse in making an initial assessment.
The accurate documentation of nurse triage findings cannot be overemphasized. Estrada (1979) argued that it is a ‘professional judgment made by a professional nurse’ deserving of careful documentation. It is a means of communication and becomes an integral part of the patient’s permanent medical record. As such, it also becomes a legal document for which the triage nurse becomes accountable and responsible and Yu & Green (2009) note, the ED chart is the only lasting record of an ED visit, and attention must be paid to proper and accurate documentation. Indeed, the principle of personal accountability is fundamental to nursing practice. Documentation should be generated for all patients presenting to the emergency setting. If the patient leaves the department without waiting to see the doctor, it may be the only record of his attendance (Southard 1989).
When documenting the triage findings, a diagnosis should not be made. The purpose of nurse triage, as previously discussed, is not to establish a diagnosis. The initial assessment made by the triage nurse is no substitute for a full clinical examination, as diagnostic investigations may need to be carried out prior to any definitive diagnosis being made. In quieter departments, if the size of the caseload allows, other clinical information may be added: past medical history, allergies, medication, etc. These data may be used to initiate patient care plans and structured around the nursing model being used in the department. Duplications of information should be avoided, however, as the patient will be asked similar questions by the doctor or nurse practitioner.
It must be recognized that there is little point in a triage episode which delays the patient being examined by a clinician and it should be kept as short as possible.
As triage is a fundamental cornerstone of clinical risk management in the emergency care setting, inaccurate triage is as much of a problem for the department as no triage, as there is no guarantee of safe clinical priorities and this would soon become a governance issue.
Triage systems must be both reproducible, so that every clinician will come to the same triage decision about the same patient, and continuous audits should be carried out to ensure that the quality of triage is consistent and that practitioners who are less than accurate are identified so that support mechanisms can be put in place. Initial training of staff in triage methodology does not guarantee ongoing competence. Mentoring after initial training is required and an assessment of competence should be carried out. Audit ensures ongoing competence and underpins the quality agenda. Areas that need to be examined include completeness of the documentation and accuracy of the decisions made.
Without complete documentation, the decision made may still be accurate, but there is no way of proving how and on what basis the decision was made. It might then have been a random decision which just happens to be correct.
A simple method of audit is to take a number of randomly generated triage episodes for each practitioner and examine them:
• completeness of the episode can be expressed as a simple proportion
• accuracy can be expressed as a simple proportion
The auditor should be an expert triage practitioner who is fully conversant with the triage method used in a particular department. Unless clinicians within the area are experienced triage practitioners and undertake triage regularly, it is not appropriate for them to audit the practice of those who do.
To ensure consistency of audit, a sample, perhaps 10 % of episodes assessed, should be assessed independently by a second expert practitioner. Any differences in perception or decision would be moderated by discussion between the two.
Continuous audit can be time-consuming but is more effective than a set audit period where the triage practitioners know that their work is going to be scrutinized and may perform to a different standard than usual.
The issue of uniformity and triage practice has been the subject of considerable discussion and debate. Following similar initiatives in Australia and Canada, a joint working party with members from both the Royal College of Nursing (RCN) ED Association and the British Association for ED Medicine (BAEM) led to the development of a standard five-point triage scale (Crouch & Marrow 1996). The scale was defined in terms of the maximum time the patient should wait before definitive clinical intervention.
Triage categories are linked to ‘time to clinician’ targets and, while the scale has been modified as reforms in emergency care and system redesign have led to 98 % of patients being discharged from the ED within a window of four hours, in general, the categories still apply to all patients attending the emergency care setting.
The categories are colour-coded, in rainbow fashion, from red for the patient needing immediate attention to blue for those patients who have a non-urgent problem.
A number of triage systems are in place throughout the world and some of these are discussed here.
Emergency Triage, which has become known as the Manchester Triage System (MTS) was first published in 1996 and was the result of the recognition by clinicians in EDs around Manchester, UK, that triage over the health economy was a muddle. A group of around 20 senior emergency physicians and nurses from each general and specialist ED spent a considerable amount of time formulating a solution that would be used in all EDs across the city. It was never envisaged that the system would extend outside the city; however, it seemed to appear at a time when triage was identified as an absolute necessity in most EDs and MTS became the triage system of choice in at least 90 % of the UK’s EDs. It appears that the system is generic enough and timely enough to have caught the imagination of EDs across the world (Martins et al. 2009, van der Linden et al. 2012). MTS has become the national triage system of Portugal and Brazil and is used extensively in a number of European countries and beyond. It is now used, translated into many languages, to triage tens of millions of ED attenders each year.
This triage method aims to give a clinical priority to each patient. It was recognized very early on in the group’s deliberations that the length of the triage consultation means that any attempt to diagnose at triage is fraught with difficulty and doomed to fail. Even if diagnosis were possible, it is not necessarily linked to the patient’s clinical priority, as other issues, such as the level of pain, will change the triage priority. It was also recognized by the group that the triage practitioner tends to look for a symptom and then hypothesize around a particular presentation or diagnosis, seeking symptoms and signs that give them permission to allocate the patient a higher triage priority, rather than assuming the worst and then eliminating signs and symptoms and moving down to a lower priority – a much safer way of working.
The key feature of the MTS is that it is reductive. The worst scenario and highest triage category is used until the patient can definitely be removed from that category (Mackway-Jones et al. 2005). Categories are time-based and this time is the time to clinical intervention rather than time to physician.
The triage practitioner is required to choose from a range of 50 presentational flow charts and seek a limited number of signs and symptoms at each level of priority. The signs and symptoms that discriminate between the different priorities are called discriminators and the assessment is carried out by finding the highest level at which the answer given to a discriminator question is positive.
Presentational flow charts are consistent in their approach so that whether the triage practitioner chooses the ‘Unwell Adult’ chart or the ‘Diarrhoea and Vomiting’ chart with which to assess a patient, the same priority will apply.
A number of general discriminators apply to every chart:
From the perspective of the patient, pain is a major factor in determining priority and the use of this as a general discriminator in every chart recognized the priority placed on pain by the patient. The MTS has been criticized for giving pain this level of priority, the concern being that patients will exaggerate their pain in order to achieve a higher priority for care; however, this is not borne out in practice. Pain should be part of every triage assessment as it is the most frequent symptom which prompts a patient to attend any emergency care setting (Fry et al. 2012). Ignoring pain is to ignore what is often most important to the patient. The use of a pain tool with behavioural characteristics such as that in the MTS allows the clinician to amend a pain score based on whether behaviour matches the patient’s perceived pain matching the objective with the subjective pain scores, and this may be a move upwards as well as downwards. The use of appropriate analgesia at triage enables pain to be managed early in the patient encounter, and dynamic triage should ensure that a triage priority can be amended if required as pain is controlled. As Fry et al. (2012) also note, unnecessary suffering may be avoided if the public had a better understanding of pain and the benefits of pain management.
One of the key tenets of the MTS is that clinical priority should not be confused with management. Different patients will be managed differently in different emergency settings. It may be appropriate to manage, for example, children, quickly, but this decision should not effect a change in clinical priority. The priority is decided by their presentation and the management by the needs and particular circumstances of the department.
There has been some criticism of the MTS triage model since its inception, based on the lack of evidence for its claim to fitness for purpose and its lack of evaluation. While consensus may be the weakest form of evidence, where it is the only evidence it has credibility. Since its introduction, research has emerged to validate the system, in contrast to many other triage systems and a number of publications are available (Cooke & Jinks 1999, Roukema et al. 2006, Matias et al. 2008, Martins et al. 2009, van der Linden et al. 2012).
Each presentation is based on the best available evidence and has been updated in the second edition as clinical guidelines have changed. A national training strategy is in place for those units who use this method of triage.
MTS has now been validated by research and by its use throughout the world. Changes in emergency care practice have led to the recognition that it can be used as part of the streaming process in a concept known as the presentation priority matrix (Mackway-Jones et al. 2005). As the emergency care ‘village’ becomes more of a reality, the ED may not be the most appropriate place for the presenting patient to receive care.
Presentations and discriminators can be mapped against disposition for each emergency care setting: for example, chest pain priority 1 will always go to the resuscitation area.
An eye problem may always go to an Emergency Eye Centre where there is one, but may be seen in the general ED where there is no specialist eye provision. Torso injury at level 4 or 5 might be appropriately streamed to the minor injury unit.
Each emergency ‘village’ can create a matrix of presentations and dispositions for their local health economy in discussion with all those involved in emergency care provision, including the ambulance service, who can then also work to ensure that patients get the best care in the best place at an appropriate time.
Disposition will, of course, be influenced by what services are available at a particular time. For instance, the minor injury unit or primary care centre may be closed in the evenings, by the current pressures on these services and by the patient’s choice.
The Australasian Triage Scale (ATS) was developed in Australia from a comprehensive review of the Australian National Triage Scale and was released in 2001 (Fitzgerald et al. 2011). The five categories are based on time to doctor, although this is being debated as nurse clinician roles are ever-developing. The category 1 patient is immediate and the category 5 should be seen within 2 hours.
All patients presenting to an ED should be triaged on arrival by a specifically trained and experienced registered nurse. The triage assessment and ATS code allocated must be recorded. The triage assessment involves a combination of the presenting problem and general appearance of the patient and may be combined with pertinent physiological observations. Vital signs are only measured at triage to estimate urgency or if time permits.
Clinical descriptors are listed for each triage category based on available research evidence and expert consensus. The list is not exhaustive or absolute and is considered to be indicative only. Physiological measurements should not be used as the only indicator for allocating to a triage category (Australasian College for Emergency Medicine 2005).
During revision of the National Triage Scale, it was recognized that there were many problems associated with inconsistency of application of the scale and also with education for the triage role and, in 2002, the Australian Commonwealth funded the development of a Triage Education Resource Book. The content of the book was developed with the assistance from professional organizations that represent ED nurses and the Australasian College for Emergency Medicine and this is used as the basis for triage training (Australasian College for Emergency Medicine 2005).
The Canada Triage and Acuity Scale was developed, based on the National Triage Scale in Australia. Its use became official policy in Canada in 1997 (Zimmermann 2006a). Categories are time-based and congruent with the ATS.
The Canadian ED triage and acuity scale is based on establishing a relationship between a group of sentinel events which are defined by the ICD9CM diagnosis at discharge from the ED, or from an in-patient database, and the ‘usual’ way patients with these conditions present. There are over 160 possible presentations with many additional modifiers which change priority.
Re-evaluation of patients is built into the system and nurses are encouraged to upgrade the triage level of patients with lower triage scores if the time objective has not been met. Reassessment is also recommended, at different intervals for different categories of patients; level 4 patients should be reassessed every hour and level 5 every 2 hours.
The Canadian Association of Emergency Physicians (CAEP) states that:
1. all patients should be assessed, at least visually, within 10 minutes of arrival
2. full patient assessments should not be done in the triage area unless there are no other patients waiting; only information required to assign a triage level should be recorded
3. a primary survey (rapid assessment) should be used when there are two or more patients waiting to be triaged, and only after all patients have had some assessment done should level 4 and 5 patients have a more complete assessment done by a triage or treatment nurse
4. priority for care may change following a more complete assessment or as patient’s signs and symptoms change. There should be documentation of the initial triage as well as any changes. The initial triage level is still used for administrative purposes
5. level 1 and 2 patients should be in a treatment area and have the complete primary nursing assessment done immediately.
Lists of ‘usual’ presenting complaints and case scenarios are available to the triage nurse but are, again, not considered to be absolute. Triage personnel are encouraged to use their experience and instincts to ‘up triage’ priority, even if the patient does not seem to fit exactly with the facts or definitions on the triage scale, and the triage practitioner is asked to consider ‘If they look sick then they probably are’. The CAEP strongly suggest that the triager’s instinct should not be used to lower the triage level assignment when the facts suggest there may be a problem, but to take the more serious possibilities first and have someone find the proof that nothing is wrong (Canadian Association of Emergency Physicians 2006). Lee et al. (2011) found it to have high validity for elderly patients, and it is an especially useful tool for categorizing severity and for recognizing elderly patients who require immediate life-saving intervention.
This was developed in the US in the late 1990s. Acuity and complexity are summarized on a 5-point scale where 1 is the highest acuity (Friedman Singer et al. 2012). Triage is based on acuity and on the likely resource consumption required to achieve a disposition and add what the patient needs on to when they need it (Zimmermann 2006b). Resources include radiography, medications and laboratory tests and resource determination is the triage nurse’s best guess based on experience of what the patient is likely to need. After the most life-threatening presentations are dealt with, patients needing 2 or more resources are Emergency Severity Index (ESI) 3, one resource is ESI4 and none is ESI5. Vital signs are used to make a triage decision about patients at ESI level 3 and above.
Emergency care continues to develop and care settings and organizations continually strive to meet the needs of patients and the demands of purchasers of services and central government. What is clear is that emergency care is dealing with infinite demand in a context of finite resources. Strategies such as Streaming and See and Treat aim to address some of the problems of a demand-led service, and where the resources match the service needs, where every patient in a minor stream can be met at the door and treated immediately, triage in the minor areas of emergency care settings is not required. The moment that definitive management is delayed and a queue develops, risk is generated where patients with unknown problems are waiting for assessment.
Triage in other areas of ED must follow the same pattern. Where each patient can be treated immediately, triage is not required; however, for almost all of the time, a robust triage system will be needed to discriminate between those patients who need immediate and life-saving intervention and those who have a lower clinical priority.
Triage, when undertaken correctly as a rapid assessment and prioritization strategy, is the gold-standard risk-management tool in emergency care throughout the world, however, as Kunz-Howard (2011) notes, triage is a process not a place. Experience and continuous education along with continuous audit lead to expert clinicians who can triage effectively and manage the work of the emergency care setting in the way that the patients deserve.
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