The extinction of triage.

In the past few decades, the volume of patients seeking emergency department care has risen, while the number of hospitals across the U.S. has declined. This means that today’s hospitals must evolve to accommodate more patients. Facilities are operating with limited staff and space resources, and seek to optimize their processes to achieve the highest efficiency, without sacrificing quality or safety. Triage is one part of emergency department management that has undergone a critical re-evaluation to enhance efficiency, while following standards of care. We describe the results of our hospital’s process redesign. The concept of triage is believed to have originated in France during the Napoleonic era. Baron Dominique-Jean Larrey, Napoleon’s surgeon, was credited with both the creation of a precursor to the modern ambulance unit and a classification system for prioritizing the wounded on the battlefield.1 In its earliest medical origins, military triage placed highest value on those soldiers who could be quickly returned to battle. Arguably, however, it was not until the Vietnam era that military triage principles were brought to American soil and applied to the civilian hospital setting. During this time, civilian helicopter ambulances, paramedic services, and resources to handle mass casualties began to evolve on the home front. As hospital emergency department’s grew in volume, size and sophistication, so too did the variety of triage processes nationwide. The current comprehensive triage goal is to gather enough information about the patient to determine the acuity, or level of severity of the illness, of the patient. This level determines the rapidity of care that needs to be delivered to the patient; i.e. whether that patient has an immediate or urgent potentially lifeor limb-threatening illness, or can safely wait for the care that is expected. There are many different examples of triage systems currently in use in the United States; for example, some hospitals use a two-level triage (emergent versus non-emergent), while others use up to a five level triage (Resuscitation, Emergent, Urgent, Non-urgent, Referred). The Emergency Severity Index (ESI), a five-level triage scale developed by Drs. Richard Wuerz and David Eitel, has become the most widely used system in the US.2 The ESI triage system sorts patients based both on their need for medical attention and their anticipated use of resources (lab, imaging, etc) in the emergency department. Many hospitals have developed nursing order protocols or experimented with physician or midlevel providers at triage. At Kent Hospital, in Warwick, RI, we report on a delivery of care model designed to rapidly and safely bring the appropriate patients to the appropriate area of the emergency department. Before the process changes in patient triage and evaluation that were implemented in July 2011, the Emergency Department (ED) at Kent Hospital was typical of many larger-thanaverage-sized community hospitals across the U.S. (Figure 1). Patients would present at the ED entrance via private vehicle, ambulance, or other means and would be triaged by a registered nurse. Some patients arriving by ambulance would have this evaluation process completed after being placed in a patient bed. This process would involve the collection of demographic information, vital signs, and a nursing assessment of the patient’s presenting complaint and current medical condition. Full registration of the patient was also frequently accomplished in this model. This process would often take 5-15 minutes, and based on the results of this triage evaluation, the patient would be placed in a patient care room where they would subsequently wait for evaluation by a medical provider, or in a chair in the ED waiting room if the patient was deemed to be medically stable and there were no available patient care rooms. We abandoned this triage process because of its many flaws. Patients would not necessarily have rapid access to medical care, and as a result would often wait for long times before necessary treatment and testing were initiated. At our hospital, and at many emergency departments nationwide, patients would often wait up to several hours before Annual ED Volume