Emory Pediatric Emergency Medicine
http://pediatrics.emory.edu/pem
Prioritizing Patient Care in an Era of Overcrowding
Naghma S. Khan, MD
Pediatric Emergency Medicine
Emory University School of Medicine
Children’s Healthcare of AtlantaJune 5, 2009
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Introduction
ED Challenges• Overcrowding• Space constraints• Nursing and physician shortage• Increasing non-urgent patient volumes in the ED• Decreasing reimbursement
Triage methods through the ages• Three-tier• Five-tier
Emergency Severity Index (ESI) Triage• Agency for Healthcare Quality Improvement
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Gaining capacity
Build a larger ED• Cost - $$$$• Space• 5-10 year plan – predictions fall short
Decrease throughput• Turnover rooms with greater frequency• No added cost• Decreased walk-out rates – increased revenue• Improved patient satisfaction• Increased capacity
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Impact of throughput times on ED capacity
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ED Flow
Input Throughput Output
Emergency CareSeriously ill from the community and referral sources
Unscheduled Urgent CareLack of available ambulatory careDesire for immediate care
Safety Net CareVulnerable populationsAccess barrier
Demand for ED care
Ambulance diversions
Patient arrives to ED
Triage and room placement
Diagnostic evaluation and
treatment
ED boarding of inpatients
Ambulatory Care System
Transfer to outside facility
Admit to hospital
Left without being seen
Patient Disposition
Lack of access to follow-up care
Lack of available staffed inpatient beds
COURTESY ACEP
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ED Overcrowding!
Input Throughput Output
Emergency CareSeriously ill from the community and referral sources
Unscheduled Urgent CareLack of available ambulatory careDesire for immediate care
Safety Net CareVulnerable populationsAccess barrier
Demand for ED care
Ambulance diversions
Patient arrives to ED
Triage and room placement
Diagnostic evaluation and
treatment
ED boarding of inpatients
Ambulatory Care System
Transfer to outside facility
Admit to hospital
Left without being seen
Patient Disposition
Lack of access to follow-up care
Lack of available staffed inpatient beds
COURTESY ACEP
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The Need to Prioritize
Input Throughput Output
Emergency CareSeriously ill from the community and referral sources
Unscheduled Urgent CareLack of available ambulatory careDesire for immediate care
Safety Net CareVulnerable populationsAccess barrier
Demand for ED care
Ambulance diversions
Patient arrives to ED
Diagnostic evaluation and
treatment
ED boarding of inpatients
Ambulatory Care System
Transfer to outside facility
Admit to hospital
Left without being seen
Patient Disposition
Lack of access to follow-up care
Lack of available staffed inpatient beds
COURTESY ACEP
Triage and Room Placement
Triage and Room Placement
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Triage
French verb “trier” - to separate, sort, sift or select Prioritization of patients based on the severity of illness/ injury
Here’s a copy of our new triage plan…..the order is “walking wounded” first, the dying and dead second, lawyers last…….
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Food for thought
Ultimate Goal• Get the patient to a doctor
Is triage (sorting) necessary if there is a bed, a doctor and resources available and no wait?
Is a nurse assessment essential for ALL patients
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The History of Triage
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History
Napoleonic Wars (early 1800’s)– Battlefield Triage• Likely to live, regardless of care• Likely to Die, regardless of care• Immediate care would make a positive difference
Evolution over time• Pre-hospital triage• Mass Casualty triage• Managing ED inflow• Telephone triage/ medical advice lines
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Introduction of Triage to U.S.A
1950’sOffice-based practiceAfter hours primary care to ED’s Increase in low acuity use of ED’sOvercrowdingNeed to sort sick from non sickMilitary physicians and nurses
introduce triage
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Maturation
Traffic Director• Non-clinical person assessing arrivals and directing to
appropriate areas
Spot check• Realization that non-clinicians are inadequate to assess
patients• Used in low volume ED’s• Clerk watches ED entrance and pages the triage RN when
needed
Comprehensive • Experienced nurses• Rapidly gather “sufficient” information to determine acuity• Within a 2 to 5 minute time frame – in reality this goal is
met 22% of the time
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Comprehensive Triage
Takes longer to triage “extremes” of age Definite benefits
• Each patient is greeted by an experienced nurse
• A sick patient is immediately identified• First aid is provided as needed• The nurse is available to meet the
emotional needs of the patients and families in the waiting room
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Triage Nurse
Triage nurses require advanced clinical decision making expertise
They need to • Make complex clinical decisions, in conditions of
uncertainty with limited or obscure information, in minimal time
• Have limited margin for error• Be able to rapidly identify and respond to actual life-
threatening states• Be able to make a judgment on the potential for life-
threatening deterioration
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Triage
Decisions are made• In response to presenting signs or symptoms• No attempt is made to formulate a medical
diagnosis • Triage category is allocated based on the necessity
for time-critical intervention to improve patient outcome, potential threat to life or need to relieve suffering
• The accuracy of triage decisions is a major influence on the health outcomes of patients
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Triage Nurse
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ED Triage Goals
• To sort a group of patients who present simultaneously to the ED
• To ensure Appropriate care Appropriate location Appropriate degree of urgency
• To initiate care in response to clinical need rather than order of arrival
• To promote safety by ensuring that timing of care and allocation of resources matches the degree of illness or injury
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Triage Outcomes
Expected triage – triaged appropriately• Seen by a doctor within a suitable time frame and should
have a positive health outcome
Over triage – triaged to a higher level then indicated• This decreases the wait time for the patient, which is not
detrimental to the patient, however the inappropriate allocation of resources has the potential to adversely affect other patients
Under triage – triaged to a lower level then indicated• This prolongs the wait time until medical intervention and
there is potential for deterioration or prolongation of pain and suffering. These factors increase the risk of an adverse patient outcome
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USA Triage Protocols
Maclean: 2001 survey of 27% of all ED’s in the United States• 69% used 3-Tier Triage• 12% used 4-TierTriage• 3% used the Australian or Canadian 5-Tier Triage• 16% did not use a scale or did not answer
National Center Health Statistics: 2003• 47% used 3-Tier Triage• 20% 4-Tier Triage• 20% 5-Tier
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3-Tier
Levels• Emergent: Poses an immediate threat to life or
limb• Urgent: Requiring prompt care, but can wait
“hours”• Non-Urgent: Condition needs attention, but time is
not a critical factor Large variation in definition for each level by hospital No clear correlation with disposition Large volume of “urgent” patients – with varying
degrees of illness
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Reliability of 3-Tier Triage
Wuerz, Fernandes, Alarcon – 1998• Triage nurses and EMT’s at 2 hospitals• Rated the acuity of 5 scripted patient scenarios
using 3-tier scale• Same people repeated the triage assignment 6
weeks later• Only 24% rated all 5 cases the same in both
phases• Overall kappa (inter-observer variability) statistic
was 0.35 (0: no agreement; 1: perfect agreement)
• 3-Tier not reliable, not effective
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Four-Tier Acuity Scales
Blue – Red – Yellow – GreenAttempted to split the 3-tier “red” and
“yellows”More equitable distribution of patients
across the levelsRequires a high degree of nursing
experience to do accuratelyPoor reliability and reproducibility
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Five-Tier Triage
Australasian National Triage Scale – 1994 “This patient should wait for medical assessment and treatment
no longer than ____ minutes”
Correlates strongly with • Resource consumption• Admission rates• ED length of stay• Mortality rates
Used as a basis of ED assessment and quality of care – patients need to be seen within the triage assigned time
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Quality Goals
ATS Category Time to Doctor Compliance Goal
ATS 1 Immediate 100%
ATS 2 10 minutes 80%
ATS 3 30 minutes 75%
ATS 4 60 minutes 70%
ATS 5 120 minutes 70%
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Manchester Triage – 1997
Ascertain patients chief complaint Select 1 of 52 flow charts with an algorithm that
assigns a triage score of 1 to 5 based on a structured interview
Reliability study comparing nurse triage to senior medical staff triage• Fair to Moderate reliability
Time to doctor• 1 Immediate 0 minutes
• 2 Very Urgent 10 minutes
• 3 Urgent 60 minutes
• 4 Standard 120 minutes
• 5 Nonurgent 240 minutes
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Canadian Triage and Acuity Scale (1996)
Pediatric Modifications Initial impression of severity of illness Evaluation of presenting complaint Assessment of behavior and age related physiological
parameters Limited assessment for assigning Level 1 or 2 Full assessment for 3,4,5 Quality goal: to see a high percentage of patients in
each category in the specified time
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Time factors
• Used for quality•Allows acuity adjusted comparison of ED’s•Used for predicting staffing models for physicians and staff
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Table 1: Suggested time goals, fractile response rates and admission rates by triage level
TRIAGE LEVEL
I II III IV V
Time to care
Immediate 15 mins 30 mins 60 mins 120 mins
Fractile Response
98% 95% 90% 85% 80%
Admission Rates
70%-90% 40%-70% 20%-40% 10%-20% 0%-10%
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Outcomes
Strong correlation for admissions Inter-rater reliability high
• Physician and RN: Kappa 0.85• Physician, RN and Paramedic: Kappa 0.77
Used by paramedics for pre-hospital triage Used for staffing predictions
• Time spent by physician for each triage level Used for evaluating practice variability Is a country-wide measure of timeliness of service
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The Emergency Severity Index
Wuerz and Eitel – 1998 Fundamentally the closest to when triage originated Principal goal of triage is to facilitate prioritization of patients
based on the urgency of the condition• Which person is seen first• How many resources will they require
Patient sorting + patient streaming Underlying assumptions of the 1st 3 5-tier systems was “how long
can the patients wait There is no time allocation in ESI Dying patient - see immediately Sick appearing patient- “shouldn’t wait” The lower 3 levels are categorized based on resource needs
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4455
no
no
no
yes
yes
abnormal
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Decision Point A
Is the patient dying
•Needs an immediate airway, medication, or other hemodynamic intervention•Is already intubated, apneic, pulseless, severe respiratory distress, SpO2 < 90 percent, acute mental status changes, or unresponsive
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Decision Point B
Should the patient wait?
• Is this a high-risk situation?• Is the patient confused, lethargic or disoriented?• Is the patient in severe pain or distress?
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Decision Point C
Resource Needs
•To identify resource needs, the nurse needs to be familiar with ED standards of care – EXPERIENCE!
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Decision Point D
The Patient’s Vital Signs
•If out of range upgrade 3 to 4
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Decision Point: Pediatric Fever
Fever
•Recommendation: Check temp <3 years at triage
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Five-Tier Acuity Rating Scales
Widespread use of ESI in the United States Canadian and US nurses studied together – randomized to ESI
and CTS– Kappa for ESI 0.89– Kappa for CTS 0.91
Advantages Easy to learn and implement High degree of inter-rater reproducibility and reliability
– Kappa 0.88 Ability to predict hospitalization, resource utilization, ED
length of stay and six-month mortality Moderate correlation with physician E/M codes and nursing
workload Facilitates meaningful comparison of case mix between
hospitals
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ESI data at Children’s
1 2 3 4 5
Site 1 Admits
92.2% 43.4% 13.1% 0.9% 0.3%
Site 2 Admits
88.6% 37.2% 14.1% 1% 0.3%
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In summary
The goal of an ED visit is to see a physician The goal of triage is to prioritize patients so
• The sickest patients can be seen expeditiously• The non-urgent patients can be separated and seen in a low
acuity setting