Emergency department triage revisited 1

Triage is a process that is critical to the effective management of modern emergency departments. Triage systems aim, not only to ensure clinical justice for the patient, but also to provide an effective tool for departmental organisation, monitoring and evaluation. Over the last 20 years, triage systems have been standardised in a number of countries and efforts made to ensure consistency of application. However, the ongoing crowding of emergency departments resulting from access block and increased demand has led to calls for a review of systems of triage. In addition, international variance in triage systems limits the capacity for benchmarking. The aim of this paper is to provide a critical review of the literature pertaining to emergency department triage in order to inform the direction for future research. While education, guidelines and algorithms have been shown to reduce triage variation, there remains significant inconsistency in triage assessment arising from the diversity of factors determining the urgency of any individual patient. It is timely to accept this diversity, what is agreed, and what may be agreeable. It is time to develop and test an International Triage Scale (ITS) which is supported by an international collaborative approach towards a triage research agenda. This agenda would seek to further develop application and moderating tools and to utilise the scales for international benchmarking and research programmes. INTRODUCTION A new triage scale was introduced into the emergency department (ED) at Ipswich Hospital, Queensland, Australia 20 years ago. The Ipswich Triage Scale (ITS) was a five category scale similar to one in use at the Box Hill Hospital, Victoria, Australia. However, this scale incorporated a patient “urgency test” to discriminate between triage categories. Validation of the ITS 2 led to its adoption as the National Triage Scale (NTS) and subsequently the Australasian Triage Scale (ATS). This in turn formed the basis of the Manchester Triage Scale (MTS) in the UK and the Canadian Triage and Acuity Scale (CTAS). There are two significant issues in current triage systems. First, recent frustrations with ED overcrowding due to growing demand and access block have brought the ongoing utility and value of triage systems into question. 6 Second, other jurisdictions (particularly the USA) are yet to adopt a standardised approach. This limits opportunities for international benchmarking of ED performance and experience. The aim of this paper is to review the status of ED triage and provide guidance with regard to the future direction. The paper examines the history and evolution of triage systems, addresses the conceptual basis of triage and the research experience and makes recommendations for the future. TRIAGE IN EMERGENCY MEDICINE Triage is an essential element of modern medical care as it is necessary to assign relatively scarce resources to unlimited medical needs. Such assignments become necessary where there is a mismatch in quantum, time or location between the medical needs of patients and available resources. In emergency medicine this mismatch relates to the timeliness of care and relative resource availability. Emergency medicine, like military medicine, has little control over the rate and number of presentations. Although patient numbers are predictable at the population level, they are not predictable at the individual level. Further description of workloads by triage categories adds weight to the predictability of patient populations. In addition, major events can lead to sudden overwhelming demand. Triage in emergency healthcare is a continuous process, but is also emphasised at key points in the continuum of care. These points include extrication from the scene, on arrival at the ED, upon admission to hospital and on presentation to operating theatres. Triage systems are designed to serve the value of human life and health with fairness and the efficient use of resources. They do this by determining who will not be disadvantaged by longer waiting times and who requires immediate attention to achieve optimal outcomes. The need for triage is enhanced by the growing imbalance between needs and resources resulting from the twin challenges of access block and growing demand. Traditionally, the triage process is an intuitive element of ED nursing practice. Nurses have always reorganised queues to ensure that those unable to wait are seen first. The earliest written record of the use of triage in emergency medicine, in a systematic sense, was in the early 1960s at Baltimore, USA. However, this and other early systems lacked formal structure and organisation. In addition, there was no agreement on the categories used. Triage was often performed by clerical staff or by the patients themselves who were asked to choose whether they wished to attend “Medical” or “Surgical Casualty”. Over time, many departments began to introduce more formalised systems of triage to meet the demands of modern emergency medicine. Anything from 2 to 10 categories were used to assign patients. At the same time as more formalised systems appeared, there emerged a focus on ED performance. This led to system-wide performance evaluations of the processes and outcomes. These evaluations aligned the need to ensure patients Public Health, Queensland University of Technology, Brisbane, Australia 2 Emergency Medicine, University of Western Australia, Nedlands, Australia Department of Medicine, The University of Melbourne, Fitzroy, Australia School of Public Health, Queensland University of Technology, Brisbane, Australia Queensland Injury Surveillance Unit (QISU), Brisbane, Australia School of Nursing and Social Work, The University of Melbourne, Fitzroy, Australia Correspondence to Professor Gerry FitzGerald, Public Health, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Brisbane, Queensland 4059, Australia; gj.fitzgerald@qut.edu. au Accepted 7 July 2009 FitzGerald G, Jelinek GA, Scott D, et al. Emerg Med J (2009). doi:10.1136/emj.2009. 077081 1 of 7 Topics: xxx