Emory Pediatric Emergency Medicine
http://pediatrics.emory.edu/pem
Prioritizing Patient Care in an Era
of Overcrowding
Naghma S. Khan, MD
Pediatric Emergency Medicine
Emory University School of Medicine
Children’s Healthcare of Atlanta
June 5, 2009
Introduction
 ED Challenges
• Overcrowding
• Space constraints
• Nursing and physician shortage
• Increasing non-urgent patient volumes in the ED
• Decreasing reimbursement
 Triage methods through the ages
• Three-tier
• Five-tier
 Emergency Severity Index (ESI) Triage
• Agency for Healthcare Quality Improvement
3
Gaining capacity
 Build a larger ED
• Cost - $$$$
• Space
• 5-10 year plan – predictions fall short
 Decrease throughput
• Turnover rooms with greater frequency
• No added cost
• Decreased walk-out rates – increased revenue
• Improved patient satisfaction
• Increased capacity
4
Impact of throughput times on ED
capacity
5
10
Rooms
10
Rooms
10
Rooms
ED
Throughput:4
hours
ED
Throughput:
3 hours
ED
Throughput:
2 hours
ED Capacity:
60/day
ED Capacity:
80/day
ED Capacity:
120/day
ED Flow
Input
Throughput
Output
Lack of access to follow-up care
Ambulance
diversions
Emergency Care
Seriously ill from
the community and
referral sources
Unscheduled
Urgent Care
Lack of available
ambulatory care
Desire for
immediate care
Safety Net Care
Vulnerable
populations
Access barrier
Patient arrives to
ED
Triage and room
placement
Demand for ED
care
Diagnostic
evaluation and
treatment
ED boarding of
inpatients
Left
without
being
seen
Patient
Disposition
Ambulatory
Care System
Transfer to
outside
facility
Admit to
hospital
Lack of available staffed inpatient beds
6
COURTESY ACEP
ED Overcrowding!
Input
Throughput
Output
Lack of access to follow-up care
Ambulance
diversions
Emergency Care
Seriously ill from
the community and
referral sources
Unscheduled
Urgent Care
Lack of available
ambulatory care
Desire for
immediate care
Safety Net Care
Vulnerable
populations
Access barrier
Patient arrives to
ED
Triage and room
placement
Demand for ED
care
Diagnostic
evaluation and
treatment
ED boarding
of inpatients
Left
without
being
seen
Patient
Disposition
Ambulatory
Care System
Transfer to
outside
facility
Admit to
hospital
Lack of available staffed inpatient beds
7
COURTESY ACEP
The Need to Prioritize
Input
Throughput
Output
Lack of access to follow-up care
Ambulance
diversions
Emergency Care
Seriously ill from
the community and
referral sources
Unscheduled
Urgent Care
Lack of available
ambulatory care
Desire for
immediate care
Safety Net Care
Vulnerable
populations
Access barrier
Patient arrives to
ED
Triage and Room
Placement
Left
without
being
seen
Demand for ED
care
Diagnostic
evaluation and
treatment
ED boarding of
inpatients
Patient
Disposition
Ambulatory
Care System
Transfer to
outside
facility
Admit to
hospital
Lack of available staffed inpatient beds
8
COURTESY ACEP
Triage
 French verb “trier” - to separate, sort, sift or select
 Prioritization of patients based on the severity of illness/ injury
Here’s a copy of our new
triage plan…..the order is
“walking wounded” first,
the dying and dead
second, lawyers last…….
9
Food for thought
 Ultimate Goal
• Get the patient to a doctor
 Is triage (sorting) necessary if there is a bed, a doctor
and resources available and no wait?
 Is a nurse assessment essential for ALL patients
10
The History of Triage
11
History
 Napoleonic Wars (early 1800’s)– Battlefield Triage
• Likely to live, regardless of care
• Likely to Die, regardless of care
• Immediate care would make a positive difference
 Evolution over time
• Pre-hospital triage
• Mass Casualty triage
• Managing ED inflow
• Telephone triage/ medical advice lines
12
Introduction of Triage to U.S.A
 1950’s
 Office-based practice
 After hours primary care to ED’s
 Increase in low acuity use of ED’s
 Overcrowding
 Need to sort sick from non sick
 Military physicians and nurses
introduce triage
13
Maturation
 Traffic Director
• Non-clinical person assessing arrivals and directing to
appropriate areas
 Spot check
• Realization that non-clinicians are inadequate to assess
patients
• Used in low volume ED’s
• Clerk watches ED entrance and pages the triage RN when
needed
 Comprehensive
14
• Experienced nurses
• Rapidly gather “sufficient” information to determine acuity
• Within a 2 to 5 minute time frame – in reality this goal is
met 22% of the time
Comprehensive Triage
 Takes longer to triage “extremes” of age
 Definite benefits
• Each patient is greeted by an experienced
nurse
• A sick patient is immediately identified
• First aid is provided as needed
• The nurse is available to meet the
emotional needs of the patients and
families in the waiting room
15
Triage Nurse
 Triage nurses require advanced clinical decision
making expertise
 They need to
• Make complex clinical decisions, in conditions of
uncertainty with limited or obscure information, in
minimal time
• Have limited margin for error
• Be able to rapidly identify and respond to actual lifethreatening states
• Be able to make a judgment on the potential for lifethreatening deterioration
16
Triage
 Decisions are made
• In response to presenting signs or symptoms
• No attempt is made to formulate a medical
diagnosis
• Triage category is allocated based on the necessity
for time-critical intervention to improve patient
outcome, potential threat to life or need to relieve
suffering
• The accuracy of triage decisions is a major influence
on the health outcomes of patients
17
Triage Nurse
18
ED Triage Goals
• To sort a group of patients who present
simultaneously to the ED
• To ensure
 Appropriate care
 Appropriate location
 Appropriate degree of urgency
• To initiate care in response to clinical need rather
than order of arrival
• To promote safety by ensuring that timing of care
and allocation of resources matches the degree of
illness or injury
19
Triage Outcomes
 Expected triage – triaged appropriately
• Seen by a doctor within a suitable time frame and should
have a positive health outcome
 Over triage – triaged to a higher level then indicated
• This decreases the wait time for the patient, which is not
detrimental to the patient, however the inappropriate
allocation of resources has the potential to adversely affect
other patients
 Under triage – triaged to a lower level then indicated
• This prolongs the wait time until medical intervention and
there is potential for deterioration or prolongation of pain and
suffering. These factors increase the risk of an adverse
patient outcome
20
USA Triage Protocols
 Maclean: 2001 survey of 27% of all ED’s in the
United States
• 69% used 3-Tier Triage
• 12% used 4-TierTriage
• 3% used the Australian or Canadian 5-Tier
Triage
• 16% did not use a scale or did not answer
 National Center Health Statistics: 2003
• 47% used 3-Tier Triage
• 20% 4-Tier Triage
• 20% 5-Tier
21
3-Tier
 Levels
• Emergent: Poses an immediate threat to life or
limb
• Urgent: Requiring prompt care, but can wait
“hours”
• Non-Urgent: Condition needs attention, but time is
not a critical factor
 Large variation in definition for each level by hospital
 No clear correlation with disposition
 Large volume of “urgent” patients – with varying
degrees of illness
22
Reliability of 3-Tier Triage
 Wuerz, Fernandes, Alarcon – 1998
• Triage nurses and EMT’s at 2 hospitals
• Rated the acuity of 5 scripted patient scenarios
using 3-tier scale
• Same people repeated the triage assignment 6
weeks later
• Only 24% rated all 5 cases the same in both
phases
• Overall kappa (inter-observer variability) statistic
was 0.35 (0: no agreement; 1: perfect
agreement)
• 3-Tier not reliable, not effective
23
Four-Tier Acuity Scales
 Blue – Red – Yellow – Green
 Attempted to split the 3-tier “red” and
“yellows”
 More equitable distribution of patients
across the levels
 Requires a high degree of nursing
experience to do accurately
 Poor reliability and reproducibility
24
Five-Tier Triage
 Australasian National Triage Scale – 1994
 “This patient should wait for medical assessment and treatment
no longer than ____ minutes”
 Correlates strongly with
•
•
•
•
Resource consumption
Admission rates
ED length of stay
Mortality rates
 Used as a basis of ED assessment and quality of care
– patients need to be seen within the triage assigned
time
25
Quality Goals
26
ATS Category
Time to Doctor
Compliance Goal
ATS 1
Immediate
100%
ATS 2
10 minutes
80%
ATS 3
30 minutes
75%
ATS 4
60 minutes
70%
ATS 5
120 minutes
70%
Manchester Triage – 1997
 Ascertain patients chief complaint
 Select 1 of 52 flow charts with an algorithm that
assigns a triage score of 1 to 5 based on a
structured interview
 Reliability study comparing nurse triage to senior
medical staff triage
• Fair to Moderate reliability
 Time to doctor
•
•
•
•
•
27
1
2
3
4
5
Immediate
Very Urgent
Urgent
Standard
Nonurgent
0 minutes
10 minutes
60 minutes
120 minutes
240 minutes
Canadian Triage and Acuity Scale (1996)
 Pediatric Modifications
 Initial impression of severity of illness
 Evaluation of presenting complaint
 Assessment of behavior and age related
physiological parameters
 Limited assessment for assigning Level 1 or 2
 Full assessment for 3,4,5
 Quality goal: to see a high percentage of patients in
each category in the specified time
28
Time factors
• Used for quality
•Allows acuity adjusted comparison of ED’s
•Used for predicting staffing models for
physicians and staff
29
TRIAGE LEVEL
I
Time to care Immediate
II
III
IV
V
15 mins
30 mins
60 mins
120 mins
Fractile
Response
98%
95%
90%
85%
80%
Admission
Rates
70%-90%
40%-70%
20%-40%
10%-20%
0%-10%
Table 1: Suggested time goals, fractile response rates and admission
rates by triage level
30
Outcomes
 Strong correlation for admissions
 Inter-rater reliability high
• Physician and RN: Kappa 0.85
• Physician, RN and Paramedic: Kappa 0.77
 Used by paramedics for pre-hospital triage
 Used for staffing predictions
• Time spent by physician for each triage level
 Used for evaluating practice variability
 Is a country-wide measure of timeliness of service
31
The Emergency Severity Index
 Wuerz and Eitel – 1998
 Fundamentally the closest to when triage originated
 Principal goal of triage is to facilitate prioritization of patients
based on the urgency of the condition
• Which person is seen first
• How many resources will they require
 Patient sorting + patient streaming
 Underlying assumptions of the 1st 3 5-tier systems was “how long
can the patients wait
 There is no time allocation in ESI
 Dying patient see immediately
 Sick appearing patient“shouldn’t wait”
 The lower 3 levels are categorized based on resource needs
32
Patient dying?
yes
no
1
Shouldn’t wait?
yes
no
How many resources
none one
many
5
4
2
Vital signs
abnormal
no
33
3
Decision Point A
 Is the patient dying
•Needs an immediate airway, medication, or other
hemodynamic intervention
•Is already intubated, apneic, pulseless, severe respiratory
distress, SpO2 < 90 percent, acute mental status changes, or
unresponsive
34
Decision Point B
 Should the patient wait?
• Is this a high-risk situation?
• Is the patient confused, lethargic or disoriented?
• Is the patient in severe pain or distress?
35
Decision Point C
 Resource Needs
•To identify resource needs, the nurse
needs to be familiar with ED standards
of care – EXPERIENCE!
36
Decision Point D
 The Patient’s Vital Signs
•If out of range upgrade 3 to 4
37
Decision Point: Pediatric Fever
 Fever
•Recommendation: Check temp <3
years at triage
38
Five-Tier Acuity Rating Scales
 Widespread use of ESI in the United States
 Canadian and US nurses studied together – randomized to ESI
and CTS
– Kappa for ESI 0.89
– Kappa for CTS 0.91
 Advantages
 Easy to learn and implement
 High degree of inter-rater reproducibility and reliability
– Kappa 0.88
 Ability to predict hospitalization, resource utilization, ED
length of stay and six-month mortality
 Moderate correlation with physician E/M codes and nursing
workload
 Facilitates meaningful comparison of case mix between
hospitals
39
ESI data at Children’s
40
1
2
3
4
5
Site 1
Admits
92.2%
43.4%
13.1%
0.9%
0.3%
Site 2
Admits
88.6%
37.2%
14.1%
1%
0.3%
In summary
 The goal of an ED visit is to see a physician
 The goal of triage is to prioritize patients so
• The sickest patients can be seen expeditiously
• The non-urgent patients can be separated and seen in a low
acuity setting
41