1. Triage – It’s a Risky Business Randy M. ZettleJoy McCarron MD, CCFP (EM), LLB, FCFPRN, BScN Borden Ladner GervaisMaster Trainer Triage, OHA TorontoSr. Leader ER Clinical Program Cancer Care Ontario - ATC April 27, 2015

2. Why continue to Triage in Ontario ER’s? Best Practice Nationally Accreditation Standard Ministry funding source Implications

3. What’s the Cost? RankCategory 1Maternal/Neonate - Failure to interpret/respond to abnormal fetal status 2Medical/Surgical - Failure to appreciate status changes/deteriorating patients 3Maternal/Neonate - Failure to monitor fetal status 4Maternal/Neonate - Mismanagement of induction/augmentation medications 5Infection Control - Healthcare acquired infections 6 Inadequate triage assessment / re-assessment 7Diagnostic - Misinterpretation of laboratory/diagnostic imaging 8Falls - Patients 10Diagnostic - Failure to perform and/or communicate critical test results 11Maternal/Neonate - Failure to communicate fetal status 12Falls - Visitors 2015 Risk Ranking (by claim costs)

4. Ministry funded OHA Train-the-Trainer Program Roll-out Nurses receive an initial 8-hour standardized training session focused on Critical Look, Chief complaint, Subjective and Objective data, vital signs, important modifiers, leading to a CTAS Code, Reassessment priorities Education and Knowledge Retention

5. So every triage nurse is up to date? Experts believe there are variations in practice CTAS codes applied not consistent with CTAS Guideline Inconsistent in-hospital training Failure to update to current standards which have evolved Local rules applied to Triage Documentation not consistently complete

6. The Importance of the Initial CTAS Level

7. It determines the timeline of subsequent care

8. Canadian Emergency Department Triage & Acuity Scale (CTAS) CTAS 1 (resuscitation) – immediate & continuous CTAS 2 (emergent) – within 15 minutes CTAS 3 (urgent) – within 30 minutes CTAS 4 (less/semi-urgent) – within 1 hour CTAS 5 (non-urgent) – within 2 hours

9. It establishes the timeline to physician assessment

10. It establishes the timeline for Triage Reassessments

11. Question 1 Does the triage nurse need to obtain and interpret a complete set of vital signs at triage? A) Yes B) No C) Only for CTAS 1, 2 and 3's

12. Vital Signs at Triage A waste of time?

13. Just a little cut on my head…

14. Question 2 It is not necessary to perform and document Triage Reassessments when: 1. the Triage Nurse has told the patients to advise him/her if their condition changes 2. the patient has a very minor condition (CTAS 4 or 5) 3. there is reduced coverage at the Triage Desk because of breaks/meals 4. the patient is seen and assessed by the MD/NP within the recommended CTAS time interval

15. Triage Reassessments (the Safety of Waiting)

16. Is it sufficient for the Triage Nurse to tell patients to return to the Triage Desk if their symptoms or condition changes?

17. The Bottom Line - Do them and document them at an appropriate frequency

18. Why? Because the initial Triage is: - a static assessment of a dynamic disease process - a ‘snapshot’ of the patient’s illness in time

19. The Importance of Documentation Cannot be Over-emphasized: Contemporaneous, appropriate and sufficiently detailed documentation/records are extremely important in proving the: - care that was provided - steps that were taken on behalf of the patient - communication with other healthcare providers

20. Re-prioritization of patients Triage is a process, not just a number on a scale. Processes need to be managed! CTAS Education Program

21. Question What percentage of initial triage scores are incorrect or not consistent with the CTAS Guideline based on triage documentation? A) 0 - 10 % B) 10 - 20 % C) 30 - 40 %

22. Are your triage nurses getting it right? Auditor General Audit 2010 “…one-half of files that were re-assessed… the CTAS levels originally assigned by triage nurses were incorrect. Of these, the majority were under-triaged.” Independent Expert Retrospective Audit of 5000+ charts “30% of charts were under-triaged. Themes of under-triage included not aligning score with vital signs (especially Pediatric), ignoring stated pain score, missed signs and symptoms of potential cardiac presentation and potential sepsis.”

23. Questions ?