Issue 14 / 22 April 2013

AFTER countless “emergency” calls for incorrect triage — especially those that disrupt sleep and busy office sessions — I am well aware of the inconsistencies of the emergency department.

I am therefore relieved that the Emergency Triage Education Kit (ETEK) is under review.

Triage is a French term, derived from military medicine. The concept started with three categories in the Napoleonic wars and was revived in World War I.

The Australasian Triage Scale (ATS) is a modern variation on the original theme, ranging from triage 1 for patients with life-threatening conditions who should be seen immediately in 100% of cases, to triage 5 for patients whose condition is less urgent with at least 70% of patients to be seen within a 2-hour waiting time.

I have pored over the ETEK and Australasian College of Emergency Medicine (ACEM) guideline documents aimed at good triage, and believe there are a number of problems and incorrect assumptions.

For example, ACEM suggests that a blood sugar level (BSL) of more than 16 mmol/L warrants a triage 3, meaning 75% of patients are to be seen within 30 minutes. There must be thousands of Australians in community and nursing homes with BSLs above 16 mmol/L, many of whom are not even aware of it. A BSL of 26 may be closer to the mark for a triage 3.

The ETEK is full of examples of what I consider plain nonsense, such as the recommendation that an otherwise well 47-year old who hurt his wrist playing volleyball and has a good range of movement with some pain on rotation be seen within an hour.

Or a 27-year old travelling to India in a week who presents for advice about vaccines who “should wait no longer than 2 hours”. And a man whose girlfriend is concerned about a mole on his back should be seen within 2 hours to exclude melanoma.

The ETEK is more reliable with the triage 1 and 2 categories. It also states that “environmental factors such as staffing, skill-mix and ED activity level must not influence urgency allocation”.

There are particular challenges in rural and remote areas when no doctor is on site or even in the town. Multiple casualties are another challenge — if several triage 1 or 2 patients present at once, it requires a very skilled and calm clinician to prioritise.

We also need to be mindful of the time from presentation to triage, as well as the time from triage to treatment. In too many EDs, big and small, patients spend excessive time filling in forms and registering before they’re even triaged.

ACEM conducted a literature review recently and published the following ideas:

  • The ATS in its current form should only be used to describe urgency
  • Separate measures are needed to describe severity, complexity, workload and staffing, and to assess quality of care
  • Standard definitions are needed for terms such as urgency, severity and complexity as they are used interchangeably, contributing to confusion

These points are valid, but I would like to add some of my own:

  • The National Triage Working Party include representatives of rural and remote doctors, GPs, physicians and surgeons to prevent inappropriate triaging (eg, are emergency physicians really trained to advise on travel vaccines and melanoma?)
  • Triage 6 be established for cases that need to be seen on the day but are by no means an immediate threat to patient’s health
  • Triage 7 be introduced for patients that should not be seen in EDs at all
  • Patients in triage 5, 6 and 7 be billed privately if seen by a doctor in ED or be sent to a primary care setting
  • Ambulance officers have more responsibility for triage in the field, so patients are taken to appropriate facilities, especially in rural areas.

The ETEK review is a golden opportunity to address many important issues. We have to teach the public — and ourselves — to stop confusing convenience, urgency and emergency.

The term “emergency department” is fast becoming a misnomer as EDs are increasingly used as medical convenience stores.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 22 April 2013

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11 thoughts on “Aniello Iannuzzi: Triage needs treatment

  1. Seb says:

    What will happen if a patient is given priority 5-7, goes home to avoid the fee and dies? Who is responsible, the triage nurse?

  2. Peter McInerney says:

    Good article Aniello and timely. As you point out the system has so many weaknesses. All your points are valid. The triage system is meant to apply to emergency presentations but of course ED’s are now being used as go to places for non urgent issues and “free” consultations.
    One of the major weaknesses is who actually assigns the score. Appropriate scoring requires skilled history taking and good clinical acumen both of which may be absent, especially in rural hospitals.

  3. ED physician says:

    I find it quite amusing that the authors main complaint regarding the ATS is that he is disrupted by inconvenient phone calls regarding potentially urgent patients.
    Nonetheless, the article makes some valid points. Triage is an essential part of any ED system to aid the allocation of limited resources to those most in need of urgent care. The ATS was derived from the Ipswich Triage Scale that also had 5 categories, which were seconds; minutes; one hour; hours and days.
    The ATS is a cynically politicised version of the ITS, and was adopted by ACEM to reflect a view that “community standards” demand any patient with any complaint is seen promptly in the ED. This suited the college which could use it to argue the case for a vast expansion in the specialist ED workforce to meet targets that are not grounded in any clinical reality beyond the fact that ATS 1 and 2 patients should be seen very quickly. This has now become so ingrained in the thinking of governments that it has led to blunt instruments such as the NEAT aka “four hour rule” to drive clinical care.
    One would hope that a review of the ATS would correct some of this insanity, but as ACEM is in a Faustian pact with governments that run EDs it seems highly unlikely that this will occur. We are losing sight of the purpose of emergency medicine, and my own college is complicit in this.

  4. Keltic RN ED says:

    The triage scale has as many variables as a Merck manual. Attempting to scale this into 5 ‘time slots’ is a bureaucratic, not a practical, or even useful measure….and as for the ‘four hour rule’…that might wash with the voters…but until there are sufficient hospital BEDS to plant BUMS in, with the STAFF to look after them ‘adequately’ (ha-bloody-ha), the four hour rule is a JOKE!! Triage works (mostly) in CAT 1 & 2 cases, then falls right over….it’s hard to get ‘dead’ and ‘nearly dead’ wrong!

  5. ED Doctor says:

    There is no doubt that emergency medical care can and is delivered by a range of medical practitioners and in a range of facilities. This does include Emergency Departments (as locations) as well as Emergency Physicians (as treating Medical practitioners) …however there are lots more locations and providers around..including rural GP’s who don’t have the luxury of the resource of a clinician sitting in the local version of the ED .

    ….as the move towards defining and measuring clinical outputs continues under the guise of setting appropriate community standards, alternate options need exploring.

    Whether the initial precipitant was a political decision (probably in the 80’s) – the demand for “emergency care” continues to creep higher and the resources being made available especially remain stagnant.
    I am not sure the answer is steeped totally in a definition change.

  6. Ben says:

    I’ve never seen a cat 5 for anything other than a repeat prescription, so I don’t think we need 6-7 just yet.

  7. TB,EdDoc says:

    Great article Aniello – all the essential points made well! However, ‘in-field’ triage categories generally apply to both observed damage and level of compensation that the organism has managed to muster, ie, vital signs. With ED triage, a further problem is that it includes the “what-if” factor, eg, any chest pain is recommended to attract a Cat 2, (or at the very least a Cat 3), even if there are no apparent cardiac risk factors, on the basis that the pain “could” be cardiac in origin. Rarely it is, much more commonly it isn’t. The problems go on and on.
    Although we certainly do have plenty of Cat 5s, I agree with Aniello that there are multiple presentations that should be triaged “OUT” of the ED. A further issue certainly does relate to the “one-stop-free-shop” factor, which creates an inescapably good business-growth model and the resulting, observed exponential growth of ‘business’ which is attracted to EDs.
    Solution? Politically unpalatable! We all know how to improve the problem, workplace suggestions abound, but the FUNDHOLDERS won’t do it! Perhaps going back to a model like the one in the UK might just work? We certainly won’t know until we try. Good luck!

  8. Dr W says:

    The system is only as good as those using it. My introduction to Australia 15 years ago was to be woken at 2 in the morning to clear a normal cervical spine xray so the patient could go home. My questions about the patient’s level of consciousness and range of movement went unanswered. There was no neurology.
    I think it is unreasonable to expect virtually all patients with actual pathology to see a doctor within 2 hours. A truly urgent patient cannot afford to wait the 2 hours, those with pathology not that urgent could well be sent off to come back the next day. The real questions are: 1) Will this patient die if I don’t see them now? 2) Will this patient die, suffer irreparable damage, or become critically ill if they are not seen tonight?
    Even a broken finger or nose, while painful and deserving of sympathy, will probably survive until the next day.
    We need to differentiate between desirable outcomes and necessary outcomes.

  9. David Mountain (Emerg Consultant) says:

    I can feel the unhappiness that Aniello feels about his perceived wasted time and disturbed sleep. I have no doubt that at times his (as in any ED) has attendees who seem to him to be wasting his time. Unfortunately the consequences of not having medical review of patients, and an underlying philosophy that “they” (your patients) are time wasters, are playing out at Northam hospital in WA and have done so at many other smaller hospitals. Perhaps Aniello’s triage staff would never feel pressured just to turn some one away to keep the Doc in bed (but I bet they do) and then end up with a catastrophe on their hands. There were 6 deaths in Northam and at least 3 of them were in part due to just these sort of issues and severe under triage and inadequate assessments. Triage is a blunt tool that provides a way of deploying constrained resources to achieve adequate care in a timely way. It is a system that is dependent on local resources and, yes, in small communities – particulalrly ones with poor GP patient ratios and long delays to GP appointment – there will be large numbers of low acuity attendances, it is a problem just as much for your poor triage nurse (if not devolved to the triage (non medical) clerk! It is clearly a system that is dependent on experience, skill and can be distorted by individuals. However as Winston C said of democracy “It has been said that democracy is the worst form of government except all the others that have been tried” and the same is true of the Australian Triage Scale. Unless you have some meaningful and validated system to trial just dismembering what you already have without something better to replace it invites anarchy and poor patient outcomes. You may get some more sleep in the short term but once those disasters start happening I doubt the sleep will last.

  10. Sue Ieraci says:

    It’s likely that Aniello’s dissatisfaction is based on the fact that not all ED’s are “equal”. The ATS was designed for EDs with on-site medical staff and multi-patient presentations, where there needed to be a scale to assist prioritisation. There have been long discussions about whether the ATS should be applied in exactly the same way in small rural hospitals without on-site medical staff. With respect to my rural colleagues, many did not want to accept that there might be different types of “EDs” for which different expectations are logical, and so, insisted that “an ED is an ED”. It is important to remember that the ATS is not designed for general practice, where the prevalence of acute illness or injury requiring hospital admission is relatively low (about 1% admission rate vs 30% or higher for EDs). ATS is not about making appointments – it is a way of prioritising all-comers. Once a patient presents, how long is it reasonable for them to have to wait. Our College believes that 2 hours is long enough. Having said that, we are now becoming more sophisticated with processes like streaming by complexity (not just urgency) and having specific pathways for chest pain etc. There is some evidence that the five-scale ATS could be simplified – although the first two categories would remain (they are the most strongly evidence-based). I would invite Aniello to present his own data on the relationship between waiting time and clinical outcomes at a big urban or rural base ED, apply it to all the presentations and see what improvements he can make.

  11. Sue Ieraci says:

    This final comment of Aniello’s also deserves comment: “The term “emergency department” is fast becoming a misnomer as EDs are increasingly used as medical convenience stores.” I’m not entirely sure whether being convenient is a bad thing, but the comment suggests a misunderstanding of ED casemix. In a small town where there is no on-site doctor in the ED, one cannot make a clear distinction between the ED and the rural general practice. In the setting where the vast majority of ED occasions of service happen, however, there is a major difference in casemix, urgency, complexity and severity. In major centres, over 40% of patients require admission to hospital. For those who are dischaged, the ED may have provided a second opinion for a referring GP, or excluded something significant like AMI or PE, or done some procedure or test that the GP was unable, unwilling or unavailable to do. Maybe the problem is not the ATS, but the persistence in naming every walk-in facility an “ED”.

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