Quality measures: Triage and Triage performance

Vanessa Thornton

Clinical Head ED Middlemore Hospital

Triage

• From the French word trier to “sort or select”

• Refers to the sorting of injured or sick patients according to the need for emergency treatment.

Mandatory NZ Measure

• Patient journey time-stamps– Waiting time from triage to time

seen by a decision making clinician.

– Continuous measure

The detail • Waiting time from triage to time seen by a decision making clinician (C).

• For the purpose of this measure a decision making clinician is defined as someone who can make clinical decisions or begin a care pathway over and above triage. Traditionally the Australasian Triage Scale (ATS), with its associated performance thresholds as published by ACEM, has been used for this purpose. Many EDs are evolving towards a two tiered prioritisation system (triage 1 and 2 to be seen now, the others to be seen in order of arrival) or a three tiered system (triage 1, triage 2 and the others). The reasons for this include streaming of patients within and beyond the ED, including to fast tracks, and greater nursing assessment and treatment of patients as part of enhanced nursing practice or according to the delegated authority within agreed pathways.

• The ATS evolved within a ‘single queue for a doctor’ paradigm, and there has been much debate about its ongoing utility in modern EDs. However, it is expected that ATS triaging will continue as it is a familiar and useful tool for prioritisation, and it gives a comparable picture of case mix.

• Because of the evolution of the models of care in our EDs, comparison of an ED’s performance against the performance thresholds published by ACEM for each of the triage categories has become a less accurate indicator of quality than it once was. However, it is recommended that such comparison is made, as part of internal quality improvement processes.

A quote!

Paul Bataldens quote

“Every system is designed to get the results it gets”.

MMH Triage S/B system

• Current process at MMH is for patients to stop the clock on a Dr, CNS seen by or a chest pain pathway

• Current start of clock is at triage• We have no rapid “clock stopping”

EAT RAT or any other quick fix process

• We do have nurses instituting stat treatment but not stopping clocks!

Percentage of patients in each TC at MMH

ATS 1 = 1% 100%TBS 0min

ATS 2 = 12.7% 80% TBS10min

ATS 3 = 50.9 % 75% TBS 30min

ATS 4 = 34.1% 70% TBS 60min

ATS 5 = 1.8% 70% TBS 120min

Data 2013

TC 1 TC 2 TC 3 TC 4 TC 5

Total 1054 13001 51995 34845 1820

Tot admit 747 6438 19994 8403 171

% of TC admitted 71% 50% 38% 24% 9%

TC 1 TC 2 TC 3 TC 4 TC 5

Pass 100% 57% 31% 50% 102%

Median/Mean Time TBS

TC 1 TC 2 TC 3 TC 4 TC 5

0 20 94 103 82 Median

0 40 81 81 78 Std Deviation

MMH Performance TC 2Target 80% seen 10min

Triage 2 Pass All Specialties VS ED

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Jul-0

9

Sep

-09

Nov

-09

Jan-

10

Mar

-10

May

-10

Jul-1

0

Sep

-10

Nov

-10

Jan-

11

Mar

-11

May

-11

Jul-1

1

Oct

-11

Dec

-11

Feb

-12

Apr

-12

Jun-

12

Aug

-12

Oct

-12

Dec

-12

Feb

-13

Apr

-13

Jun-

13

Aug

-13

Oct

-13

Dec

-13

Month-Year

% o

f T

C p

as

s

All Pass% EC pass %

Triage Cat 3 patientsTarget 75%seen in 30min

Triage 3 Pass All Specialties VS ED

00.05

0.10.15

0.2

0.250.3

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Month

Pere

ntag

e

All Percentage Pass EC % Pass

Triage Cat 3 patientsTarget 75%seen in 30min

Triage 3 Pass All Specialties VS ED

00.05

0.10.15

0.2

0.250.3

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Month

Pere

ntag

e

All Percentage Pass EC % Pass

ACEM review of ATS Answered these questions

1. What is the evidence for the validity for the current waiting times and performance thresholds?No validation studies linking the priority of maximum waiting times but ATS is more reliable in ATS 1 and 2

2. Is the ATS still a valid tool for differentiating urgency?Is a valid scale for differentiating clinical urgency and ATS 1 and 2 most reliable

3. How do triage tools satisfy other dimensions of acuity such as provider related intensity, staff workload and complexity of patient diagnosis?Triage tools are not valid for dimensions apart form urgency

4. What is the evidence for time thresholds and the role of the ATS in prioritising workload and the assessment of burden of work.ATS is an insufficient indicator of workload

Research at MMH

• You were less likely to die if you were outside of your maximum waiting time in triage category 3?

• Higher triage category patients (i.e. ATS category 1) were more likely to die, and spend less time in hospital before they die.

• Patients who died and were seen outside of the ATS category maximum waiting times were more likely to be in ATS categories 3 and 4. They were also more likely to be referrals to medicine or other inpatient specialties.

• This study provides no conclusive evidence that patients who are seen outside their ATS category maximum waiting times are disadvantaged in terms of mortality, with the possible exception of ATS category 1 patients.

Reflection at MMH

• MMH result on TC 3 and 4 is about design

• We have at times 25 patients arrive in 1 hour and at most 8 Drs

• Can we get a better result • Of course• Will it improve the quality of care?

Conclusion • TC are a measure of urgency

• Evidence around cat 1 and 2 that quality changes for the time critical treatments

• TC 3,4,5 patients…. is there enough evidence for the ATS performance thresholds and max waiting times

• MMH cannot reach these targets in the current design