OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also:

• administrative issues
• vital signs, clinical deterioration, MET calls, acute illness scoring systems (eg. NEWS)
• ACEM policy - Australasian Triage Scale Nov 2000 (pdf)
  • “Where Emergency Department resources are chronically restricted, or during periods of transient patient overload, staff should be deployed so that performance is maintained in the more urgent categories.”
  • “Prolonged waiting times for undifferentiated patients presenting for emergency care is viewed as a failure of both access and quality.”
  • ACEM Triage Guidelines Implementation (pdf)
• ACEM paper - ATS 4 and 5 are DIFFERENT to GP type patients (pdf)
• "non urgent" patients in the ED

• patients dead on arrival are usually given an ATS category of 6.

Introduction

The Australasian Triage Scale (ATS) was agreed upon in the late 1980's and arose out of sorting systems to categorize patients arriving at the hospital's emergency department in order of urgency. Dr Ed Brentnall OAM was a key figure. As Director of Box Hill ED the system he implemented closely resembled the one we now use.

Historically, triage can be traced to battlefield decision-making and the efforts to save the most lives. Overwhelming numbers of injured fallen led to a need to prioritize who would be treated and in what order.

Triage is not an indicator of whether a person should have attended the ED. And triage should not be a tool for turning people away from the ED.

Triage Category 3 is classified as “Urgent” which translates to a waiting time recommendation of “Less than 30 minutes”.

The normal day at Sunshine ED sees about 85 of the 240 or so people arriving to Triage being allocated a category of 3.

Staffing is distributed in rostered shifts in such a way as to best meet the needs of these arriving patients.

Situation

More than two-thirds of Triage Category 3 patients are not given access to a cubicle or are not able to have a focused history taken by a doctor within the recommended maximum wait time of 30 minutes.

This is a diverse group of patients, some of whom have high-risk, high-lethality medical conditions.

A Triage Category 3 patient in the waiting room beyond 30 minutes starts to accumulate unmanaged risk.

Previously a RAZ system was implemented to try to address this issue.

RAZ has enjoyed limited success chiefly due to a lack of consistent staffing for that “care-model”, but also due to its day and evening shift implementation without night shift support.

Risk-reduction strategies which are workable during the night shift hours of 10.30pm to 7.30am are the main aim of this initiative. If the night shift staff find the processes detailed here useful, then scaling the methods up to cover the day and evenings shifts is reasonable.

Background

The demography of Western Melbourne has determined the rising overall attendances to Sunshine ED. The Hospital frequently suffers from crowding (bed occupancy well over 100% capacity) which leads to access block (admitted patients boarding in the ED for more than 8 hours after presentation).

The hospital is also situated in a region of low health-literacy and low socio-economic means.

For these two reasons people may present late in the course of their illness and may be less inclined to advocate for themselves and their family. A large number of at-risk patients are not fluent in English.

Assessment

Triage Category 3 patients are quite likely to discharge-prior-to-being-seen which poses an unacceptable risk to themselves. Last month the DNW (Did Not Wait) percentage was above six for Triage Category 3.

Those who do wait, may suffer a deterioration in their condition while in the waiting room, which could have consequences in terms of the safety and effectiveness of their management.

Triage Category 3 patients (who by definition have urgent clinical issues) would be reassured if their local hospital attended to them in a timely fashion, and this could lead to a drop in complaints.

Request

At the commencement of each shift medical staff are advised to hand over all Triage Category 3 patients who are yet to be seen by a doctor.

The on-coming doctor in charge is advised to update tracking-screen notes at this time to reflect urgency of review.

Re-triage remains the best option for mitigating risk. This can be communicated to the nurse in charge and the triage and flow nurses.

The ED Status application (copyright Dr G. Ayton) can be used to get a glimpse of unseen Category 3 patients, their triage notes, and the wait time. Modifications can be made to this program after feedback is obtained from staff.

The following steps could be used to help manage excess Triage Category 3 waits. This is a joint task for our doctors in charge, nurses in charge, and flow nurses.

Identify Risk Factors:

1. Patients who are not fluent in English
2. Elderly patients (age >74)
3. Patients with abnormal vital signs or pain persisting after analgesia
4. Those with a history of ESRF or CRF
5. Any patient whose triage assessment leads to concern or diagnostic doubt

Order and Review Imaging:

In line with recent strategies to help the efficiency of Fast-track it is possible to organise high-yield imaging studies from the waiting room - for instance CXR, CT-Brain and CT-KUB.

The hospital is working towards an ED-driven request system for non-constrast CT for specific indications which will not require approval from an off-site radiology registrar.

Make use of the sonosite ultrasound early in the assessment of Category 3 patients who are in a cubicle to evaluate their problem and assist in disposition.

Provision of more timely imaging for certain patient groups may lead to a reduction in adverse outcomes.

Advocate for the patient:

Early communication with the access manager (“after hours” or “bed manager”) to escalate appropriately the need for waiting room patients to gain entry to ED cubicles. Wards may be able to assist by taking another patient on a four-hour plan.

Prioritise at-risk Category 3 patients for access to cubicles. Although bringing waiting room patients directly into EOU may be an option, the potential for cognitive errors, inefficient bed use, and queue errors make this strategy less likely to be a viable solution.

Explain the wait:

Provide explanation to patients and to colleagues regarding realistic time-frames for assessment and management.

Managing each patient's (and their family's) expectations is part of our role in providing rapid care in a busy Emergency Department.

References

Ayton, G., “EDStatus.exe” desktop application, Desiderata Software.

Dunn, R., Brookes, J., Rogers, I., et al, Emergency Medicine Manual.

Burke, J.A., Greenslade, J., Two hour evaluation and referral model for shorter turnaround times in the emergency department, EMA, Vol 29, Issue 3, 2017.