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Do We Need Triage?
TRIAGE DECISIONS
DO WE NEED TRIAGE? Author: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, Lexington, KY Section Editors: Andi L. Foley, MSN, RN, CEN, and Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN
mergency nurses inherently believe that we need triage to prioritize patients. Using triage as a process to sort patients is appropriate. However, in many facilities, triage has evolved over time into a place as opposed to a process. Triage has become a sacred cow in many emergency departments. When triage is a place where patients must stop, bottlenecks may occur, resulting in an increased length of stay. In an environment where the focus is on safety and efficiency, triage as a place should no longer occur. Triage as a process can be the driver that enhances overall throughput. Patients come to the emergency department to see a provider. Processes that inherently slow presentation to provider time may compromise safety, as well as patient and staff satisfaction. Traditional triage as a place does not facilitate getting the patient to the provider quickly. Many solutions have been attempted to reduce door-to-provider times: bedside registration, immediate bedding, emergency departments without waiting rooms, and keeping patients vertical. Although some time gains may be achieved by using these solutions, these same strategies could prove to be ineffective. What changes need to occur to minimize delays from presentation to provider? The triage nurse needs to know about the population that presents to the emergency department. When will patients arrive, how many will arrive at a time, how many will arrive per hour, and how sick will they be? Each facility has these data, and they should be used to allocate resources so that patients do not end up in a queue at the front end waiting to be seen. As emergency nurses, we have an obligation to ensure that triage is a true sorting of those who are sick from those who are not sick. Persons who are sick should be taken immediately to a treatment
E
Patricia Kunz Howard, Member, Bluegrass Chapter, is Operations Manager, Emergency and Trauma Services, University of Kentucky Chandler Medical Center, Lexington, KY. For correspondence, write: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, 2108 Thorndale Way, Lexington, KY 40515; E-mail: [email protected]. J Emerg Nurs 2011;37:597. Available online 9 September 2011. 0099-1767/$36.00 Copyright © 2011 Emergency Nurses Association. Published by Elsevier. All rights reserved. doi: 10.1016/j.jen.2011.08.008
November 2011
VOLUME 37 • ISSUE 6
area, and those not as sick may go to an intake area. Assessment and care provided in the intake area should include documentation of the chief complaint and vital signs. Every patient does not need a bed. Keeping low-acuity patients vertical or in a chair setting for care will decrease length of stay and optimize efficiency. We don’t really need triage—at least, not triage as a place. For triage as a process to be effective, the walls of triage must go away. Care processes traditionally associated with triage can be done at the sides of stretchers or chairs as the patient’s condition dictates. The initial encounter with the patient should include a “quick look.” The emergency nurse’s first assessment of the patient’s appearance gathers sufficient information when combined with the stated chief complaint to determine the appropriateness of use of a stretcher or chair in the intake area. How do we remove the barriers of triage as a place? It is essential that a team of stakeholders with ownership in the current triage process work together. These stakeholders include nursing, registration, greeters, providers, and administration, at a minimum. Once the team is established, begin by looking at current processes to identify every step in the patient’s trajectory through the ED visit. Enlist the help of “lean teams” or simulation to determine where silos or delays in getting the patient to a care provider exist. Identifying delays leads to rapid-cycle testing of solutions to eliminate delays. Team members need to be willing to submit any potential solutions to a trial. No areas are off limits. The goal must be to eliminate causes of delays in getting the patient to the care provider. Triage evolved to a place over time. In battlefields, where the concept of triage developed, triage did not occur in any particular location other than where the patients were found. Returning triage to a process that occurs in any location that most rapidly facilitates getting the patient to the care provider for definitive care is the right approach for safety and the right approach to ensure that the patient has the best possible outcome.
Submissions to this column are encouraged and may be sent to Andi L. Foley, MSN, RN, CEN [email protected] or Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN [email protected]
WWW.JENONLINE.ORG
597
DO WE NEED TRIAGE? Author: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, Lexington, KY Section Editors: Andi L. Foley, MSN, RN, CEN, and Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN
mergency nurses inherently believe that we need triage to prioritize patients. Using triage as a process to sort patients is appropriate. However, in many facilities, triage has evolved over time into a place as opposed to a process. Triage has become a sacred cow in many emergency departments. When triage is a place where patients must stop, bottlenecks may occur, resulting in an increased length of stay. In an environment where the focus is on safety and efficiency, triage as a place should no longer occur. Triage as a process can be the driver that enhances overall throughput. Patients come to the emergency department to see a provider. Processes that inherently slow presentation to provider time may compromise safety, as well as patient and staff satisfaction. Traditional triage as a place does not facilitate getting the patient to the provider quickly. Many solutions have been attempted to reduce door-to-provider times: bedside registration, immediate bedding, emergency departments without waiting rooms, and keeping patients vertical. Although some time gains may be achieved by using these solutions, these same strategies could prove to be ineffective. What changes need to occur to minimize delays from presentation to provider? The triage nurse needs to know about the population that presents to the emergency department. When will patients arrive, how many will arrive at a time, how many will arrive per hour, and how sick will they be? Each facility has these data, and they should be used to allocate resources so that patients do not end up in a queue at the front end waiting to be seen. As emergency nurses, we have an obligation to ensure that triage is a true sorting of those who are sick from those who are not sick. Persons who are sick should be taken immediately to a treatment
E
Patricia Kunz Howard, Member, Bluegrass Chapter, is Operations Manager, Emergency and Trauma Services, University of Kentucky Chandler Medical Center, Lexington, KY. For correspondence, write: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, 2108 Thorndale Way, Lexington, KY 40515; E-mail: [email protected]. J Emerg Nurs 2011;37:597. Available online 9 September 2011. 0099-1767/$36.00 Copyright © 2011 Emergency Nurses Association. Published by Elsevier. All rights reserved. doi: 10.1016/j.jen.2011.08.008
November 2011
VOLUME 37 • ISSUE 6
area, and those not as sick may go to an intake area. Assessment and care provided in the intake area should include documentation of the chief complaint and vital signs. Every patient does not need a bed. Keeping low-acuity patients vertical or in a chair setting for care will decrease length of stay and optimize efficiency. We don’t really need triage—at least, not triage as a place. For triage as a process to be effective, the walls of triage must go away. Care processes traditionally associated with triage can be done at the sides of stretchers or chairs as the patient’s condition dictates. The initial encounter with the patient should include a “quick look.” The emergency nurse’s first assessment of the patient’s appearance gathers sufficient information when combined with the stated chief complaint to determine the appropriateness of use of a stretcher or chair in the intake area. How do we remove the barriers of triage as a place? It is essential that a team of stakeholders with ownership in the current triage process work together. These stakeholders include nursing, registration, greeters, providers, and administration, at a minimum. Once the team is established, begin by looking at current processes to identify every step in the patient’s trajectory through the ED visit. Enlist the help of “lean teams” or simulation to determine where silos or delays in getting the patient to a care provider exist. Identifying delays leads to rapid-cycle testing of solutions to eliminate delays. Team members need to be willing to submit any potential solutions to a trial. No areas are off limits. The goal must be to eliminate causes of delays in getting the patient to the care provider. Triage evolved to a place over time. In battlefields, where the concept of triage developed, triage did not occur in any particular location other than where the patients were found. Returning triage to a process that occurs in any location that most rapidly facilitates getting the patient to the care provider for definitive care is the right approach for safety and the right approach to ensure that the patient has the best possible outcome.
Submissions to this column are encouraged and may be sent to Andi L. Foley, MSN, RN, CEN [email protected] or Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN [email protected]
WWW.JENONLINE.ORG
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