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Triage and ATS: Collateral damage in the quest to improve ED performance

2012; Elsevier BV; Volume: 15; Issue: 4 Linguagem: Inglês

10.1016/j.aenj.2012.09.002

1839-2776

Julie Considine, Ramon Z. Shaban, Gerard FitzGerald, Shane Thomas, Colin A. Graham,

Healthcare Systems and Technology

Australia is a world leader in the development and validation of triage scales. The National Triage Scale (NTS) was introduced in 1993, later becoming the Australasian Triage Scale (ATS) in 20001Australasian College for Emergency Medicine. Policy Document: The Australasian Triage Scale. Retrieved 2 June 2010 from http://www.acem.org.au/media/policies_and_guidelines/P06_Aust_Triage_Scale_Nov_2000.pdf; 2000 (reviewed 2006).Google Scholar, 2Australasian College for Emergency Medicine. Guidelines on the Implementation of the Australasian Triage Scale in Emergency Departments. Retrieved 2 June 2010 from http://www.acem.org.au/media/policies_and_guidelines/G24_Implementation__ATS.pdf; 2000 (revised 2005).Google Scholar effecting a nationally consistent approach to ED triage with descriptors on maximum acceptable waiting times for patients. Both the NTS and ATS have well validated and have formed the basis of other triage systems in use internationally.3Forero R. Nugus P. Australasian College for Emergency Medicine Literature Review on the Australasian Triage Scale (ATS). University of New South Wales, Australian Institute of Health Innovation, Sydney2012Google Scholar Standardised triage systems optimise patient safety in the face of excessive demand for services, afford efficiency of ED services, and ensure equity of access to health services across the population.4Gerdtz M. Considine J. Sands N. Stewart C. Crellin D. Pollock W. et al.Emergency Triage Education Kit. Australian Government Department of Health and Ageing, Canberra2007Google Scholar The practise of triage including application of the ATS is underpinned by: (i) a robust body of research demonstrating its efficacy, and (ii) a national triage education program based on a systematic approach to patient assessment and evidence-based discriminators for ATS application to adults (including pregnant women), children and also patients suffering from mental health issues, pain, and ophthalmic emergencies.4Gerdtz M. Considine J. Sands N. Stewart C. Crellin D. Pollock W. et al.Emergency Triage Education Kit. Australian Government Department of Health and Ageing, Canberra2007Google Scholar Both leading professional emergency care colleges in Australia, the College of Emergency Nursing Australasia and the Australasian College for Emergency Medicine, maintain that the ATS is a valid tool for prioritisation of patients and their emergency care according to clinical urgency.3Forero R. Nugus P. Australasian College for Emergency Medicine Literature Review on the Australasian Triage Scale (ATS). University of New South Wales, Australian Institute of Health Innovation, Sydney2012Google Scholar, 5College of Emergency Nursing Australasia (CENA). Position Statement: Triage and the Australasian Triage Scale. Burwood, NSW: College of Emergency Nursing Australasia (CENA). Retrieved 17 July 2012 from http://cena.org.au/CENA/Documents/2012_06_14_CENA_Position_Statement_Triage_FinalD2-1.pdf; 2012.Google Scholar Like many other countries, Australian EDs are struggling with increasing demand for emergency healthcare services,6Australian Institute of Health and Welfare. Australian hospital statistics 2010–11: emergency department care and elective surgery waiting times. Canberra: Australian Institute of Health and Welfare. Health services series no. 41. Cat. no. HSE 115. Retrieved 30 January 2012 from http://www.aihw.gov.au/publication-detail/?id=6442472405; 2011.Google Scholar, 7Lowthian J.A. Curtis A.J. Jolley D.J. Stoelwinder J.U. McNeil J.J. Cameron P.A. Demand at the emergency department front door: 10-year trends in presentations.Med J Aust. 2012; 196: 128-132Crossref PubMed Scopus (205) Google Scholar overcrowding and access block.8Asplin B.R. Magid D.J. Rhodes K.V. Solberg L.I. Lurie N. Camargo Jr., C.A. A conceptual model of emergency department crowding.Ann Emerg Med. 2003; 42: 173-180Abstract Full Text Full Text PDF PubMed Scopus (604) Google Scholar, 9Derlet R. Overcrowding in emergency departments: increased demand and decreased capacity.Ann Emerg Med. 2002; 39: 430-432Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar, 10Higginson I. Emergency department crowding.Emerg Med J. 2012; 29: 437-443Crossref PubMed Scopus (88) Google Scholar, 11Pines J.M. Hilton J.A. Weber E.J. Alkemade A.J. Al Shabanah H. Anderson P.D. et al.International perspectives on emergency department crowding.Acad Emerg Med. 2011; 18: 1358-1370Crossref PubMed Scopus (392) Google Scholar, 12Hoot N.R. Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions.Ann Emerg Med. 2008; 52 (126–36.e1)Google Scholar In an attempt to enhance quality of care by improving ED performance, the Australian Government implemented the National Emergency Access Target (NEAT) or ‘four hour rule’.13Geelhoed G.C. de Klerk N.H. Emergency department overcrowding, mortality and the 4-hour rule in Western Australia.Med J Aust. 2012; 196: 122-126Crossref PubMed Scopus (170) Google Scholar, 14Baggoley C, Owler B, Grigg M, Wellington H, Monaghan M, Hartley-Jones J. Expert Panel Review of Elective Surgery and Emergency Access Targets under the National Partnership Agreement on Improving Public Hospital Services. Canberra: Report to the Council of Australian Governments. Retrieved 20 June 2012 from http://www.coag.gov.au/docs/Expert_Panel_Report%20D0490.pdf; 30 June 2011.Google Scholar In implementing NEAT, ED triage has come under intense criticism and scrutiny with calls for it to be abolished or at least modified. One modification calls to replace the ED nurse triage with a system where arriving patients are assessed within minutes by a ‘staff member’ capable of initiating and managing their care.15Newnham H. Smit P.D. Keogh M. Strip M. Cameron P. Emergency and acute medical admissions: insights from US and UK visits by a Melbourne tertiary health service.Med J Aust. 2012; 196: 101-103Crossref PubMed Scopus (9) Google Scholar Under this system, patients will require allocation to an area within the ED where staffing skill mix and resources match their clinical urgency so there will still be a triage process, however termed.15Newnham H. Smit P.D. Keogh M. Strip M. Cameron P. Emergency and acute medical admissions: insights from US and UK visits by a Melbourne tertiary health service.Med J Aust. 2012; 196: 101-103Crossref PubMed Scopus (9) Google Scholar Proponents of this model suggest that ED triage in its entirety results in “nursing staff categorising the relative urgency of patient care rather than initiating treatment”.15Newnham H. Smit P.D. Keogh M. Strip M. Cameron P. Emergency and acute medical admissions: insights from US and UK visits by a Melbourne tertiary health service.Med J Aust. 2012; 196: 101-103Crossref PubMed Scopus (9) Google Scholar The authors do acknowledge that triage is a “necessary response to a crowded waiting room and is aimed at safely managing a delay,”15Newnham H. Smit P.D. Keogh M. Strip M. Cameron P. Emergency and acute medical admissions: insights from US and UK visits by a Melbourne tertiary health service.Med J Aust. 2012; 196: 101-103Crossref PubMed Scopus (9) Google Scholar but we argue this view fails to recognise that both initial assessment of clinical urgency and secondary triage decisions that decrease time to care, investigations, symptom relief, and promotion of comfort17King D.L. Ben-Tovim D.I. Bassham J. Redesigning emergency department patient flows: application of lean thinking to health care.Emerg Med Austral. 2006; 18: 391-397Crossref PubMed Scopus (215) Google Scholar, 18Ben-Tovim D.I. Bassham J.E. Bolch D. Martin M.A. Dougherty M. Szwarcbord M. Lean thinking across a hospital: redesigning care at the Flinders Medical Centre.Aust Health Rev. 2007; 31: 10-15Crossref PubMed Scopus (132) Google Scholar constitutes treatment. The Australian Institute for Health and Welfare (AIHW) data suggests that there is still work needed to achieve “wait free” emergency care. In 2010–11, 70% of patients were seen within the recommended time for their triage category6Australian Institute of Health and Welfare. Australian hospital statistics 2010–11: emergency department care and elective surgery waiting times. Canberra: Australian Institute of Health and Welfare. Health services series no. 41. Cat. no. HSE 115. Retrieved 30 January 2012 from http://www.aihw.gov.au/publication-detail/?id=6442472405; 2011.Google Scholar leaving over 1.8 million Australian ED patients in the care of triage and emergency nurses whilst waiting for further treatment. Another view is that ATS Category 1 and 2 patients should be seen immediately and ATS category 3, 4 and 5 patients in order of arrival, rather than within the existing time periods associated with each category.16Ben-Tovim D.I. Dougherty M.L. O’Connell T.J. McGrath K.M. Patient journeys: the process of clinical redesign.Med J Aust. 2008; 188: 14Google Scholar, 17King D.L. Ben-Tovim D.I. Bassham J. Redesigning emergency department patient flows: application of lean thinking to health care.Emerg Med Austral. 2006; 18: 391-397Crossref PubMed Scopus (215) Google Scholar, 18Ben-Tovim D.I. Bassham J.E. Bolch D. Martin M.A. Dougherty M. Szwarcbord M. Lean thinking across a hospital: redesigning care at the Flinders Medical Centre.Aust Health Rev. 2007; 31: 10-15Crossref PubMed Scopus (132) Google Scholar Proponents of this have claimed to have trialing such a model, which they argue “has improved access to care and reduced overall waiting times…without compromising the care of the critically ill”16Ben-Tovim D.I. Dougherty M.L. O’Connell T.J. McGrath K.M. Patient journeys: the process of clinical redesign.Med J Aust. 2008; 188: 14Google Scholar and that use of the ATS to prioritize the order in which patients were seen extends the ED length of stay.17King D.L. Ben-Tovim D.I. Bassham J. Redesigning emergency department patient flows: application of lean thinking to health care.Emerg Med Austral. 2006; 18: 391-397Crossref PubMed Scopus (215) Google Scholar It appears that in this instance the ATS was still used and that the intervention tested at a single health service was in fact the streaming of patients according to likely admission or discharge rather than an alternative of triage model.17King D.L. Ben-Tovim D.I. Bassham J. Redesigning emergency department patient flows: application of lean thinking to health care.Emerg Med Austral. 2006; 18: 391-397Crossref PubMed Scopus (215) Google Scholar In Australia, 21% of ATS 2 patients wait longer than 10 min for emergency care6Australian Institute of Health and Welfare. Australian hospital statistics 2010–11: emergency department care and elective surgery waiting times. Canberra: Australian Institute of Health and Welfare. Health services series no. 41. Cat. no. HSE 115. Retrieved 30 January 2012 from http://www.aihw.gov.au/publication-detail/?id=6442472405; 2011.Google Scholar and so simply changing the triage scale to recommend that these patients are seen “immediately” will not in our view correct this related but fundamental problem of ED performance rather than triage. Further, management of ATS 3, 4 and 5 patients in arrival order raises risk management and ethical issues. Seeing patients with pain after patients without pain is unethical and seeing patients with normal physiology before patients with abnormal physiology presents unjustifiable risks to patient care and is poor clinical risk management. Given the clear relationship between abnormal vital signs and serious in-hospital adverse events (death, cardiac arrest and unplanned intensive care admission),19A prelude to outreach: prevalence and mortality of ward patients with abnormal vital signs.in: 15th annual congress of the european society of intensive care medicine. Spain Intensive Care Medicine, Barcelona2002Google Scholar, 20Bedell S.E. Deitz D.C. Leeman D. Delbanco T.L. Incidence and characteristics of preventable iatrogenic cardiac arrests.JAMA. 1991; 265: 2815-2820Crossref PubMed Scopus (137) Google Scholar, 21Bellomo R. Goldsmith D. Uchino S. Buckmaster J. Hart G. Opdam H. et al.A prospective before-and-after trial of a medical emergency team.Med J Aust. 2003; 179: 283-287PubMed Google Scholar, 22Berlot G. Pangher A. Pettrucci L. Bussani R. Lucangelo U. Anticipating events of in-hospital cardiac arrests.Eur J Emerg Med. 2004; 11: 24-28Crossref PubMed Scopus (49) Google Scholar, 23Buist M. Bernard S. Nguyen T.V. Moore G. Anderson J. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study.Resuscitation. 2004; 62: 137-141Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar, 24Considine J. Thomas S. Potter R. Predictors of critical care admission in emergency department patients triaged as low to moderate urgency.J Adv Nurs. 2009; 65: 818-827Crossref PubMed Scopus (33) Google Scholar, 25Goldhill D.R. McNarry A.F. Physiological abnormalities in early warning scores are related to mortality in adult inpatients.Br J Anaes. 2004; 92: 822-824Crossref Scopus (231) Google Scholar, 26Skrifvars M. Nurmi J. Ikola K. Saarinen K. Caster M. Reduced survival following resuscitation in patients with documented clinically abnormal observations prior to in-hospital cardiac arrest.Resuscitation. 2006; 70: 215-222Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar this practice directly contradicts the overwhelming mandate for quality and safety in health care, and we would suggest leave EDs and practitioners open to indefensible medico-legal liability in the case of an adverse outcome. Calls to modify the ATS and triage practice and the arguments that underpin them persist despite clear evidence that: (i) the ATS is valid and reliable3Forero R. Nugus P. Australasian College for Emergency Medicine Literature Review on the Australasian Triage Scale (ATS). University of New South Wales, Australian Institute of Health Innovation, Sydney2012Google Scholar and (ii) clinician decision performance using validated decision support tools is superior to using unaided judgment or tools that do not have appropriate validated performance.27Connolly A.M. Katz V.L. Bash K.L. McMahon M.J. Hansen W.F. Trauma and pregnancy.Am J Perinatol. 1997; 14: 331-336Crossref PubMed Scopus (209) Google Scholar Of the five-level triage scales currently in use globally, the ATS has a higher level of inter-rater reliability agreement than the Canadian Triage and Acuity Scale and Manchester Triage Scale (median κ = 0.54, 0.52 and 0.33 respectively).28van der Wulp I. van Stel H.F. Calculating kappas from adjusted data improved the comparability of the reliability of triage systems: a comparative study.J Clin Epidemiol. 2010; 63: 1256-1263Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The only study comparing three and five-level triage scales showed that five-level scales have increased levels of agreement, discrimination, sensitivity and specificity, and decreased rates of under-triage.29Travers D.A. Waller A.E. Bowling J.M. Flowers D. Tintinalli J. Five-level triage system more effective than three-level in tertiary emergency department.J Emerg Nurs: JEN: Off Publ Emerg Dept Nurses Assoc. 2002; 28: 395-400PubMed Scopus (145) Google Scholar Comparison of reliability measures (kappa statistics: κ) further supports that five-level triage scales are more reliable than three and four-level scales. The κ value for five-level scales ranges from 0.38 (fair) to 1.0 (very good) compared to 0.19 (poor) to 0.53 (moderate) for three and four-level scales.28van der Wulp I. van Stel H.F. Calculating kappas from adjusted data improved the comparability of the reliability of triage systems: a comparative study.J Clin Epidemiol. 2010; 63: 1256-1263Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Criticisms of the ATS and its performance quite simply do not square with this evidence. In our view, calls to abandon the ATS occur without any published evidence that the ATS is no longer valid or reliable and with no validated alternative approach to ED triage, are ill-conceived, and the arguments promulgated to justify them are unsubstantiated. The problems of ED and hospital performance, namely waiting times, ED length of stay, ambulance bypass, patient throughput and access block, have been inappropriately attributed to the ATS. Prolonged waiting times are a function of inadequate ED performance. ED overcrowding and length of stay are markers of ED and health service performance rather than indicators of the effectiveness of the ATS. Failure to meet these performance standards have resulted in calls to reject the widely validated triage tool, ATS, in favour of the alternatives outlined earlier, all of which lack a robust evidence-base. If there were calls to change other validated emergency care tools such as NEXUS,30Hoffman J.R. Wolfson A.B. Todd K. Mower W.R. Selective cervical spine radiography in blunt trauma: methodology of the national emergency X-radiography utilization study (NEXUS).Ann Emerg Med. 1998; 32: 461-469Abstract Full Text Full Text PDF PubMed Scopus (270) Google Scholar the Canadian cervical spine rules31Stiell I.G. Wells G.A. Vandemheen K.L. Clement C.M. Lesiuk H. De Maio V.J. et al.The Canadian C-spine rule for radiography in alert and stable trauma patients.JAMA. 2001; 286: 1841-1848Crossref PubMed Scopus (876) Google Scholar, 32Bandiera G. Stiell I.G. Wells G.A. Clement C. De Maio V. Vandemheen K.L. et al.The Canadian C-spine rule performs better than unstructured physician judgment.Ann Emerg Med. 2003; 42: 395-402Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar or Ottawa Ankle rules33Stiell I.G. Greenberg G.H. McKnight R.D. Wells G.A. Ottawa ankle rules for radiography of acute injuries.N Z Med J. 1995; 108: 111PubMed Google Scholar, 34Stiell I.G. Greenberg G.H. McKnight R.D. Nair R.C. McDowell I. Reardon M. et al.Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation.JAMA. 1993; 269: 1127-1132Crossref PubMed Scopus (294) Google Scholar, 35Stiell I.G. Greenberg G.H. McKnight R.D. Nair R.C. McDowell I. Worthington J.R. A study to develop clinical decision rules for the use of radiography in acute ankle injuries.Ann Emerg Med. 1992; 21: 384-390Abstract Full Text PDF PubMed Scopus (504) Google Scholar or purposefully deviate from evidence-based best practice, there would be professional outcry. The real question is not whether triage, and specifically application of the ATS, is appropriate but rather what happens to patients once they have been triaged. Nothing in adherence to the ATS would prevent creative means of fast tracking or streaming of patients in larger EDs, nor prevent innovative approaches to rapid initiation of advanced resuscitation; including nurse initiated investigation and treatment. This rejection of the ATS is both unnecessary and illogical and results from confusion between the ATS as a tool and the ED performance standards that have been linked to it. The real solution lies in developing and validating ED performance standards that are reasonable and achievable, and properly resourcing health services to achieve those standards. Triage nurses have a professional responsibility to critically examine calls to change triage practice against the current evidence base, and rather than blindly agree with alternative triage systems, demand evidence of their reliability, validity and safety prior to implementation in clinical practice.