Quality measures: Triage and
Triage performance
Vanessa Thornton
Clinical Head ED Middlemore Hospital
Triage
•
From the French word trier to “sort
or select”
•
Refers to the sorting of injured or
sick patients according to the need
for emergency treatment.
Mandatory NZ Measure
• Patient journey time-stamps
– Waiting time from triage to time
seen by a decision making
clinician.
– Continuous measure
The detail
• Waiting time from triage to time seen by a decision making clinician (C).
• For the purpose of this measure a decision making clinician is defined as someone
who can make clinical decisions or begin a care pathway over and above triage.
Traditionally the Australasian Triage Scale (ATS), with its associated performance
thresholds as published by ACEM, has been used for this purpose. Many EDs are
evolving towards a two tiered prioritisation system (triage 1 and 2 to be seen now,
the others to be seen in order of arrival) or a three tiered system (triage 1, triage 2
and the others). The reasons for this include streaming of patients within and
beyond the ED, including to fast tracks, and greater nursing assessment and
treatment of patients as part of enhanced nursing practice or according to the
delegated authority within agreed pathways.
• The ATS evolved within a ‘single queue for a doctor’ paradigm, and there has been
much debate about its ongoing utility in modern EDs. However, it is expected that
ATS triaging will continue as it is a familiar and useful tool for prioritisation, and it
gives a comparable picture of case mix.
• Because of the evolution of the models of care in our EDs, comparison of an ED’s
performance against the performance thresholds published by ACEM for each of
the triage categories has become a less accurate indicator of quality than it once
was. However, it is recommended that such comparison is made, as part of internal
quality improvement processes.
A quote!
Paul Bataldens quote
“Every
system is designed to
get the results it gets”.
MMH Triage S/B system
• Current process at MMH is for
patients to stop the clock on a Dr,
CNS seen by or a chest pain pathway
• Current start of clock is at triage
• We have no rapid “clock stopping”
EAT RAT or any other quick fix
process
• We do have nurses instituting stat
treatment but not stopping clocks!
Percentage of patients in each
TC at MMH
ATS 1 = 1%
ATS 2 = 12.7%
ATS 3 = 50.9 %
ATS 4 = 34.1%
ATS 5 = 1.8%
100%TBS 0min
80% TBS10min
75% TBS 30min
70% TBS 60min
70% TBS 120min
Data 2013
Pass
TC 1
TC 2
TC 3
TC 4
TC 5
Total
1054
13001
51995
34845
1820
Tot admit
747
6438
19994
8403
171
% of TC
admitted
71%
50%
38%
24%
9%
TC 1
TC 2
TC 3
TC 4
TC 5
100%
57%
31%
50%
102%
Median/Mean Time TBS
TC 1
TC 2
TC 3
TC 4
TC 5
0
20
94
103
82
Median
0
40
81
81
78
Std Deviation
0
All Pass%
EC pass %
Month-Year
Dec-13
Oct-13
Aug-13
Jun-13
Apr-13
Feb-13
Dec-12
Oct-12
Aug-12
Jun-12
Apr-12
Feb-12
Dec-11
Oct-11
Jul-11
May-11
Mar-11
Jan-11
Nov-10
Sep-10
Jul-10
May-10
Mar-10
Jan-10
Nov-09
Sep-09
Jul-09
% of TC pass
MMH Performance TC 2
Target 80% seen 10min
Triage 2 Pass All Specialties VS ED
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Triage Cat 3 patients
Target 75%seen in 30min
Triage 3 Pass All Specialties VS ED
Perentage
0.3
0.25
0.2
0.15
0.1
0.05
0
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
EC % Pass
Aug-13
Jul-13
Jun-13
Month
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
All Percentage Pass
Triage Cat 3 patients
Target 75%seen in 30min
Triage 3 Pass All Specialties VS ED
Perentage
0.3
0.25
0.2
0.15
0.1
0.05
0
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
EC % Pass
Aug-13
Jul-13
Jun-13
Month
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
All Percentage Pass
ACEM review of ATS
Answered these questions
1. What is the evidence for the validity for the current waiting times and
performance thresholds?
No validation studies linking the priority of maximum
waiting times but ATS is more reliable in ATS 1 and 2
2. Is the ATS still a valid tool for differentiating urgency?
Is a valid scale for differentiating clinical urgency and ATS 1
and 2 most reliable
3. How do triage tools satisfy other dimensions of acuity such as
provider related intensity, staff workload and complexity of
patient diagnosis?
Triage tools are not valid for dimensions apart form urgency
4. What is the evidence for time thresholds and the role of the ATS in
prioritising workload and the assessment of burden of work.
ATS is an insufficient indicator of workload
Research at MMH
•
You were less likely to die if you were outside of your
maximum waiting time in triage category 3?
•
Higher triage category patients (i.e. ATS category 1) were
more likely to die, and spend less time in hospital before
they die.
•
Patients who died and were seen outside of the ATS
category maximum waiting times were more likely to be in
ATS categories 3 and 4. They were also more likely to be
referrals to medicine or other inpatient specialties.
•
This study provides no conclusive evidence that patients
who are seen outside their ATS category maximum
waiting times are disadvantaged in terms of mortality, with
the possible exception of ATS category 1 patients.
Reflection at MMH
• MMH result on TC 3 and 4 is about
design
• We have at times 25 patients arrive in
1 hour and at most 8 Drs
• Can we get a better result
• Of course
• Will it improve the quality of care?
Conclusion
•
•
•
•
TC are a measure of urgency
Evidence around cat 1 and 2 that quality
changes for the time critical treatments
TC 3,4,5 patients…. is there enough
evidence for the ATS performance
thresholds and max waiting times
MMH cannot reach these targets in the
current design