Emergency department attenders

The unpredictability of workloads within emergency settings and the steadily increasing numbers of attenders are well recognized and documented (Mallet & Woolwich 1990, National Audit Office 2004, Department of Health 2010). During a 24-hour period a wide spectrum of accidents and emergencies may be seen, sometimes stretching the resources of the department and staff to their limit. Walk-in centres and NHS Direct have not been demonstrated to reduce attendance in EDs (Cooke 2005).

Prior to nurse triage, the waiting room was an unknown quantity for the ED staff. It could be full of patients with a diverse range of illnesses and injuries, of varying degrees of severity and without any screening there was a risk of a patient’s condition deteriorating while waiting to be seen. It is inevitable that with the ever-increasing demands on a finite service, longer waiting times develop and the most vulnerable group of patients, i.e., those who are seriously ill and in need of immediate emergency care and treatment, may not be identified and prioritized. Recognition of all these factors highlights the need for all patients to be assessed on arrival in the ED by a person skilled in triage.

The purpose of triage

The purpose of triage in the emergency care setting is not to reduce the overall waiting time for all patients. Mallet & Woolwich (1990) have shown, in line with other studies, that while the waiting times for the more seriously ill were reduced, overall departmental waiting times steadily increased. The purpose of triage is to ‘make the best possible use of the available medical and nursing personnel and facilities’ and it is there to assist in determining ‘which patients need immediate care … and which patients can wait’ (Potter 1985).

The role and aims of triage

In a joint statement, the College of Emergency Medicine, the Emergency Nurse Consultants Association, the Faculty of Emergency Nursing and the Royal College of Nursing Emergency Care Association (2011) defined triage as ‘a complex decision making process to manage clinical risk’. Therefore, the primary aim of the triage nurse must be the early assessment of patients, in order to determine the priority of care according to the individual’s clinical need. There are other aspects of care, however, that nurse triage can meet (Handyside 1996), for instance, more efficient use of the department facilities and resources as patients are allocated to the most appropriate clinical areas within the department and are seen and treated within an appropriate time. As triage should be a dynamic process, regular reassessment of patients ensures that the appropriateness of the care implemented can be modified as necessary.

The early and appropriate requesting of medical records or relevant previous X-rays will aid clinical assessment and diagnosis. Appropriate first-aid measures can be taken without delay and analgesia appropriate to the patient’s level of pain can be given.

The waiting area is now a known quantity and patient flow can be controlled and organized. Patients and their relatives have an easily identifiable and reliable source of information for any enquiries. This helps to relieve anxiety and reduce aggression and can increase patient satisfaction with the service (Dolan 1998).

Non-professional triage

Patients arrive in the ED, register with the receptionist and then sit in the waiting area, without any form of assessment, until they are called to be seen by the clinician. The receptionist will only call a clinician if there appears to be some reason for concern.

In the UK, non-professional triage can still be found functioning in some departments and is more frequently used at certain times, e.g., at night when staff and resources are limited. Mallet & Woolwich (1990) identified this as an area of great concern in their study of nurse triage in an inner-city ED and recommended the provision of a nurse triage service during the night shift. Their concerns are echoed in the findings of a large study of the use of health care assistants (HCAs) in English EDs, which found that HCAs assessed patients on arrival in 28.7 % of the 282 departments that responded to the survey (Boyes 1995).

Triage tends to have been recognized as a system which must be undertaken by a competent clinician; however, there are a number of emergency care settings where non-professional triage may be, while not the system of choice, the system which has to be lived with. Walk-in centres and minor injury units may not have levels of professional staff in which a qualified nurse can be allocated to a triage role. Nurses undertaking advanced practice roles are likely to be dealing with existing patients, away from the waiting area and therefore are not aware of the clinical need of those patients walking into the department.

Similarly, in general practice, the receptionist is always the first point of contact for the patient and there is little chance of a clinician being present when a patient who needs urgent care walks in. In these circumstances it is imperative that reception staff have a clear set of guidelines to work from to help them to identify those patients for whom urgent professional care must be obtained. Algorithms may be developed which reception staff are able to work through and appropriate training must be given to aid reception staff to undertake this crucial role.

Professional triage

Triage may be undertaken by a range of professionals in emergency care settings such as nurses, medical staff, ambulance paramedics and emergency care practitioners (ECPs). What needs to be common among these clinicians is experience and education. Because triage often uses algorithms to enable reproducible decisions in the care setting, it might be felt that it could be undertaken by anyone working in the setting. The level of decision-making which takes place within the rapid triage encounter requires sound clinical judgement which must be based on professional experience, knowledge and skill. The triage practitioner must be able to interpret, discriminate and evaluate the information he gathers from the patient, relative and carer and must be able to reflect on their decision-making and critically appraise it (Mackway-Jones et al. 2005).

Telephone triage

A major expansion of the triage process has been the recognition and development of telephone triage. As in the case of face-to-face triage, this strategy was first identified in the US (Simenson 2001).

Advice-giving over the telephone has always been a part of the clinician’s role, although not one that has been recognized as having a particularly distinct identity. Formalized advice-giving by telephone has the potential to be a valuable tool in many settings – a fact that has been recognized in the development of NHS Direct in England and Wales and NHS 24 in Scotland. Some 5 million calls were made to NHS Direct in England in 2009/10 (NHS Direct 2010).

Telephone triage was first described as a useful emergency care strategy in the UK by Buckles & Carew-McColl in 1991. Various benefits have been attributed to it, including reduced attendance due to explanations and self-care advice, redirection of patients to more appropriate agencies, pre-identification of patient problems, cost-effectiveness, in terms of reduction in workload, and patient empowerment.

Telephone triage has many difficulties. The patient is not visible, so many of the cues that experienced clinicians take from the patient’s appearance and behaviour are not available. The information may be gained from an intermediary such as a relative or neighbour or another health professional who may not know the patient well (Marsden 2000, Purc-Stephenson & Thrasher 2010).

Telephone triage must be approached as a distinct role and not undertaken by the member of staff who happens to be passing the telephone when it rings. Early studies of telephone triage suggested that patient assessment in telephone triage was, on the whole, subjective and required careful questioning which was often poor and carried out by unqualified personnel. A designated telephone triage clinician should be the first point of contact for telephone advice or triage in the emergency care setting. Decisions should be as reproducible as those made in face-to-face triage and, therefore, protocols or algorithms need to be developed. A key feature of these must be advice for the patient or carer – advice on self care if the decision is made that this is appropriate, but also advice for the patient or carer about what do to in the interim period between the call and the access to emergency care. This might include advice on basic life support while the ambulance service is directed to the caller.

The demarcation line between telephone advice and telephone triage is debatable. But it may be considered that triage occurs when a formalized process of decision-making takes place which allows identification of a clinical priority and allocation to predetermined categories of urgency of need for clinical evaluation and care. Many EDs and walk-in centres no longer offer telephone advice and have a direct transfer to NHS Direct or NHS 24 as appropriate.

What professional triage can become

As stated above, proponents of triage have never claimed that it reduced waiting times in the emergency care setting, merely that it acts as a risk-management tool, prioritizing services in a setting where demand often outstrips capacity. The triage encounter should be a rapid and reproducible assessment which accurately allocates a priority to each patient based on clinical need. A national triage system has been adopted in Portugal, using one of the systems most often used in the UK, the Manchester Triage System, and reports, nationally, that the triage encounter need take no more than 90 seconds (Lipley 2005).

At this initial assessment, opportunities have often been taken for clinicians to ‘add in’ other aspects of examination and investigation and the triage encounter includes much more than assessment, first aid and prioritization. It is used as a time to administer analgesia, to refer patients to X-ray or other investigations, to give advice about self-care and to initiate patient pathways to other specialties. This vastly increases the time taken to triage each patient and, whereas the triaged patients in the waiting room are a known quantity, the risk is transferred to the queue for triage. The triage assessment has become an ‘MOT’ rather than the ‘pit stop’.

Key concepts in See and Treat

There is no doubt that streaming in the ED and the use of See and Treat models has had a major effect on patient throughput (Shrimpling 2002) and has been endorsed by both the RCN Emergency Care Association and British Association for Emergency Medicine (BAEM). However, See and Treat is not without criticism, including the problems of the most senior clinicians dealing with the least serious presentations, thus potentially leaving the small number of seriously ill or injured patients being cared for by less experienced and less well supervised staff, the burn-out or boredom of senior clinicians dealing with interminable minor problems (Leaman 2003, Windle & Mackway Jones 2003) and the lack of adequate evaluation and evidence on which to roll out such programmes (Wardrope & Driscoll 2003). Literature search reveals little evaluation of See and Treat since this date with Maull et al. (2009) stating that although their fast-track strategy significantly improved service delivery to patients with minor conditions, service for patients with more acute conditions was not proportionately improved. Overall, however, department waiting times decreased.

It is clear though that where See and Treat services work optimally, where there is little or no queue and where there are always enough clinicians to manage the patient at the point of entry, triage is not necessary.

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