Eliminating Triage
Christopher DeLuca, MD, FACEP
Vice President, Performance Improvement
Emergency Resource Management, Inc.
Clinical Assistant Professor, Emergency Medicine
University of Pittsburgh, School of Medicine
Definition of Triage
The allocation of treatment to battle
and disaster victims according to a
system of priorities designed to
maximize the number of survivors.
Triage originated in military
medicine, when limited resources
faced many wounded soldiers.
Baron Larrey
Definition of Triage
Division of patients for priority of care into three categories:
1) Those who will not survive even with treatment
2) Those who will survive without treatment
3) Those whose survival depends on treatment.
When triage is applied correctly, the treatment of patients
requiring it is not delayed by useless or unnecessary
treatment of those in the other groups.
Evolution of Triage
Soldiers triaged as mortally wounded were left
on the battle field to die.
Florence Nightingale would search the
battlefields at night to care for these soldiers.
Larrey altered the established pattern by going
forward during battles to pick up the wounded
who could survive with potentially lifesaving
surgery.
Florence Nightingale
Evolution of Triage
Triage
1) Those who will not survive
even with treatment
2) Those who will survive
without treatment
3) Those whose survival
depends on treatment
Delay-age
1)
2)
3)
4)
5)
6)
7)
8)
9)
Chief complaint
Vital signs
History of present illness
Past medical history
Current medications
Allergies
Past surgical history
Mandated screening questions
Physical exam
Who cares?
CMS Quality Measure OP-20: Door to Diagnostic Evaluation
by a Qualified Medical Provider
Definition: Median Time from ED Arrival to Provider Contact
for Emergency Department Patients
Improvement noted as a decrease in the median value
Solutions
Provider in Triage
Direct-to-room Process
Direct-to-room Process
If we could do it with ambulances, why couldn’t we do it with everyone?
Lean principles utilized:
Waiting (decrease door to room/provider)
Defects (communication between intake staff and nursing staff in
department)
Over production (how do we distribute the patients evenly?)
Extra processing (how many times does the patient need to give a
history?)
Unused employee creativity (committee formed to develop the process)
Direct-to-room Process - Guide
1) Data elements required (rooms available):
- Name and DOB
- Chief complaint and Weight
2) Scripted communication plan developed to ensure nurses
and techs in treatment spaces aware of new patients
3) ED tracking board developed to alert physicians of new
patients
4) Registration and initial nursing assessment occurs at the
bedside
5) ESI when beds are full
Direct-to-room Process - Guide
Culture changes required:
1) Triage is no longer a full initial nursing assessment.
2) Nursing assessment usually not available at time of
physician assessment. Usually done simultaneously.
3) Quick registration by clinical staff, full registration by
registration staff performed at bedside.
Direct-to-room Process - Guide
Advantages:
1) 10 triage nurses vs 1
2) 5 providers in triage vs 1
Disadvantages:
1) Need to shift nursing resources
2) Information not immediately available for physicians
Direct-to-room Process - Results
Median Door to Room Time
St. Clair Hospital
70
60
50
40
30
20
10
0
58
8
1
2
1
2
1
2
2
Direct-to-room Process - Results
Median Door to Provider
St Clair Hospital
90
80
70
60
50
40
30
20
10
0
82
27
21
13
14
Questions?
delucac@upmc.edu