Triage comes in many forms, and hospitals across the globe approach it differently. Triage can involve one or two stages or go up to even five levels. The most common approaches to triage in the US are the “traffic director” or quick look, spot check and comprehensive methods, which cover a range of intensity.
No matter the process, the most widely accepted standard is that triage should take a maximum of 5 minutes (the Emergency Nurses Association advises 2-5 minutes). Studies show that triage times increase as the age demographic rises and when vital signs are completed as a part of triage (2). However, nursing experience levels did not affect triage times, presumably because triage protocols and algorithms map the course of every patient seen, regardless of the staff involved. Hospital design also plays role; the design of the space ultimately affects the movement of patients, staff and materials.
The triage process is fairly simple. Concerns arise, however, when a queue of patients waiting to be seen starts to build. Then the question becomes how long is too long for the last patient to be seen? If 10 people are waiting, is a door-to-triage time of 50 minutes acceptable? Is there a way to improve that time through better facility design?
Triage: A Quick History
Interestingly, the triage system was not widely documented until the late 1980s. In 1989, Gerry FitzGerald originated, penned and published one of the original triage systems. It became known as the Ipswich Triage Scale, which over the next five years evolved into the now readily accepted Australian Triage Schedule (ATS). The ATS became the basis for additional triage methods, including the Canadian Triage and Acuity Scale (CTAS) and its pediatric version, which uses a combination of physiologic measures and symptom complexes to assign a triage score to children using a five-level scale. This system of triage has proved to be a reliable, predictable source of outcomes and ED resources.
In 1997 emergency departments in Great Britain introduced the National Triage Scale Based Manchester Triage Scale. This form of triage integrated the use of algorithms; however, the research suggests that there are differing local interpretations and it has yet to be a Gold Standard. Sweden also introduced a five-level Medical Emergency Triage and Treatment System that employs algorithms based on vital signs.
In 1999, the Emergency Severity Index (ESI) was established with the goals of getting patients seen faster and to truly understand the resources required in the emergency department based on patient volumes and acuity levels. After some refinements, the ESI is now one of the most often used systems of triage in the US.
How Can You Choose?
Given the variety of options, which system may be best for your hospital? Research has determined that a hospital’s triage system is dependent on the facility, culture and patient mix index. The Emergency Nurses Association and American College of Emergency Physicians recommend and support a five-tier triage system, particularly highlighting the CTAS and ESI. However, studies suggest that there needs to be further study and strict formal guidelines for both triage and the education of triage nurses to ensure standardized care and predictability of outcomes, admissions and resources required in the ED.
Looking at your current design and process will help you determine if there is a need or opportunity to enhance either or both to maximize efficiency. Value stream mapping can also help identify areas of operational need. Perhaps new furniture options or institution of a protocol or policy is all you need to reach a solution and ensure your approach to triage helps treat patients most effectively and efficiently.
Research has shown that point of care supplies and quick access to CT and radiology has reduced length of stays and improved patient and staff satisfaction. Designing a triage that allows you to have access to Personal Protective Equipment and transport isolation equipment as well as a structure that provides Isolation room’s from EMS access and pathways that reduce exposure are also things to think about as you move forward. Lastly, in light of the new awareness of infectious diseases (Ebola) there are is a great need to understand the connection between design, operations, policy, protocol, education and access to critical information and supplies.
Agency for Healthcare research ad Quality (AHRQ) http://www.ahrq.gov/professionals/systems/hospital/esi/index.html
Canadian Triage and Acuity Scale (CTAS) http://caep.ca/resources/ctas
Emergency Nurses Association http://www.ena.org/Pages/default.aspx
Emergency Severity Index (ESI) http://esitriage.org/algorithm.asp?LastClicked=algorithm
National Triage Scale Based Manchester Triage Scale (NTS) http://webcast.hrsa.gov/archives/mchb/emsc/20100325/AnnotatedBibPedsTriage.2006.pdf
Travers D. Triage: How long does it take? How long should it take? J of Emerg Nursing; 25(3): 238-240
Van Gerven R, Delooz H, Sermeus W. Systematic triage in the emergency department using the Australian National Triage Scale: a pilot project. Europ J of Emerg Med; 2001, 8: 3-7
Tracey Graham is a Nurse Practitioner and healthcare consultant for Stantec based in the company’s Washington, DC office.