1. Emory Pediatric Emergency Medicine http://pediatrics.emory.edu/pem http://pediatrics.emory.edu/pem

2. 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

3. 3 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

4. 4 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

5. 5 Impact of throughput times on ED capacity 10 Rooms ED Throughput:4 hours ED Capacity: 60/day 10 Rooms ED Throughput: 3 hours ED Capacity: 80/day 10 Rooms ED Throughput: 2 hours ED Capacity: 120/day

6. 6 ED Flow InputThroughputOutput 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 Demand for ED care Ambulance diversions Patient arrives to ED Triage and room placement Diagnostic evaluation and treatment ED boarding of inpatients Ambulatory Care System Transfer to outside facility Admit to hospital Left without being seen Patient Disposition Lack of access to follow-up care Lack of available staffed inpatient beds COURTESY ACEP

7. 7 ED Overcrowding! InputThroughputOutput 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 Demand for ED care Ambulance diversions Patient arrives to ED Triage and room placement Diagnostic evaluation and treatment ED boarding of inpatients Ambulatory Care System Transfer to outside facility Admit to hospital Left without being seen Patient Disposition Lack of access to follow-up care Lack of available staffed inpatient beds COURTESY ACEP

8. 8 The Need to Prioritize InputThroughputOutput 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 Demand for ED care Ambulance diversions Patient arrives to ED Diagnostic evaluation and treatment ED boarding of inpatients Ambulatory Care System Transfer to outside facility Admit to hospital Left without being seen Patient Disposition Lack of access to follow-up care Lack of available staffed inpatient beds COURTESY ACEP Triage and Room Placement

9. 9 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…….

10. 10 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

11. 11 The History of Triage

12. 12 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

13. 13 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

14. 14 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 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

15. 15 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

16. 16 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 life- threatening states Be able to make a judgment on the potential for life- threatening deterioration

17. 17 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

18. 18 Triage Nurse

19. 19 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

20. 20 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

21. 21 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

22. 22 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

23. 23 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

24. 24 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

25. 25 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

26. 26 Quality Goals ATS CategoryTime to DoctorCompliance Goal ATS 1Immediate100% ATS 210 minutes80% ATS 330 minutes75% ATS 460 minutes70% ATS 5120 minutes70%

27. 27 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 1Immediate0 minutes 2Very Urgent10 minutes 3Urgent60 minutes 4Standard120 minutes 5Nonurgent240 minutes

28. 28 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

29. 29 Time factors Used for quality Allows acuity adjusted comparison of ED’s Used for predicting staffing models for physicians and staff

30. 30 Table 1: Suggested time goals, fractile response rates and admission rates by triage level TRIAGE LEVEL IIIIIIIVV Time to careImmediate15 mins30 mins60 mins120 mins Fractile Response 98%95%90%85%80% Admission Rates 70%-90%40%-70%20%-40%10%-20%0%-10%

31. 31 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

32. 32 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 1 st 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

33. 33 Patient dying? Shouldn’t wait? How many resources noneonemany Vital signs 1 1 2 2 3 3 4 4 5 5 no yes abnormal

34. 34 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

35. 35 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?

36. 36 Decision Point C  Resource Needs To identify resource needs, the nurse needs to be familiar with ED standards of care – EXPERIENCE!

37. 37 Decision Point D  The Patient’s Vital Signs If out of range upgrade 3 to 4

38. 38 Decision Point: Pediatric Fever  Fever Recommendation: Check temp <3 years at triage

39. 39 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

40. 40 ESI data at Children’s 12345 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%

41. 41 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