ED triage fails to speed care for the acutely ill
MedWire News: Mandatory triage may be a barrier to rapid emergency department (ED) treatment, say researchers who found that less than half of high-acuity walk-in patients see a physician within timeframes recommended by the Emergency Severity Index 5-tier (ESI-5) triage system.
"We would not argue that the ESI triage algorithm itself is responsible for the prolonged triage times, but rather how the process is implemented," Ellen Weber (University of California, San Francisco, USA) and colleagues write in the Annals of Emergency Medicine.
"In our department, triage nurses use a relatively simple triage data form and do not use standing orders, yet the delays were still substantial."
During 2008, the team's ED received 3932 high-acuity (ESI tiers 1 or 2) walk-in patients. The median time from arrival to triage completion for these patients was 12.3 minutes, which is longer than the recommended 10 minutes from arrival to seeing a physician.
Just 41% of patients completed triage within the recommended time, and this included patients who were seen immediately. Triage took longer than 20 minutes for a further 25% of patients, and more than 30 minutes for 10%.
At busy times, (10.00 to 22.00) 37.0% of patients were triaged within 10 minutes; this rose to 54.6% in quieter periods. Triage within 10 minutes was achieved for 78.0% of ESI tier 1 patients at busy times and 84.6% at quieter times. The corresponding rates for tier 2 patients were 36.3% and 54.2%.
Weber and team note that English EDs have largely abandoned triage, in the belief that it creates delay. They say that although this approach would intuitively seem unsafe, the present findings suggest that "mandatory triage may not be as safe as we think it is."
The researchers conclude: "Nontraditional ways of working should therefore be explored.
"At a minimum, EDs should consider adopting a flexible approach to triage, using different strategies at different times, adapting the style and amount of triage not only to the number of arrivals but also the availability of providers."
In an accompanying commentary, Shari Welch (Intermountain Institute for Health Care Delivery Research, Salt Lake City, Utah, USA) and Steven Davidson (Maimonides Medical Center, Brooklyn, New York, USA) said that the "cumbersome ED triage processes that have evolved both for regulatory compliance and operational control have resulted in triage as a bottleneck."
They said that triage has become a "single-point control mechanism for many noncritical functions," such as meeting regulatory requirements, documenting advance directives, HIV testing, and asking about domestic violence.
Welch and Davidson concluded: "One of our most routine and time-honored practices is no longer sustainable."
By Eleanor McDermid