Triage: Coming of age

In October 1988, Dr Gerry FitzGerald presented a free paper at the 2nd International Conference on Emergency Medicine in Brisbane. In 10 min, Gerry presented ground-breaking data from his Doctor of Medicine thesis on what he called the ‘Ipswich Triage Scale’, a five-point triage scale rating urgency according to how long a patient could wait for medical intervention. Those 10 min were to have a profound influence on patient flows and ED administration around the world. His work validated what emergency physicians and nurses knew to be true in practice, that good triage nurses were expert at what they did. Considering the short time and limited information available at triage, it was remarkable how consistently they were right. Further multicentre research on triage revealed robust evidence that linear associations existed when comparing urgency against waiting time, treatment time, doctor time, nurse time, admission rates, resource use, outcomes and so on. In 1994 at the ACEM Annual Scientific Meeting in Melbourne, after hearing this evidence presented, Bryan Walpole jumped out of his seat in characteristic fashion. ‘I think we have discovered a new biological variable’, he proclaimed with customary zeal. He was probably right. So with the assistance of a number of college committees, clinical and administrative tools for managing ED patient flows, casemix and performance management were developed based on the Australasian Triage Scale (ATS). But what all these varied applications depended on was the accuracy and reliability with which triage nurses assessed how urgently patients needed care. At that time, there was little research on the process of triage. In effect, triage nurses were like ‘black boxes’: you put a patient in front of them, and out the other end came a rating that was consistent between different triage nurses. What happened inside the ‘black box’ had not been investigated and was not well understood. Twenty years on, there has been a major effort into researching what goes on inside the ‘black box’, and trying to further improve the consistency of the output. Indeed, one of the key areas emergency medicine can claim as its own distinct intellectual property is the body of knowledge that has grown up around triage. After much follow-up work on the reliability of the ATS, the seminal Commonwealth-funded work of Whitby, Ieraci and colleagues informed the development of clinical guidelines to optimize its uniform application. This large study identified, from a national sample of 11 169 episodes of emergency care, the clinical predictors of urgency for each of the five ATS categories. These enabled the ATS guidelines to provide descriptions for each triage category according to history, general appearance and some basic physical parameters in order to guide decision-making. The paper by Gerdtz et al. in this issue of Emergency Medicine Australasia substantially strengthens this body of knowledge. Marie Gerdtz and her team have applied precise science to the process of standardization of triage. Their research will form a benchmark for future triage studies, and this is in the context of a national roll out of the Emergency Triage Education Kit (ETEK), an important initiative to provide a ‘nationally consistent approach to the educational preparation of emergency clinicians for the triage role’, and to promote ‘the consistent application of the Australasian Triage Scale (ATS)’.