1. Quality measures: Triage and Triage performance Vanessa Thornton Clinical Head ED Middlemore Hospital

2. 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.

3. Mandatory NZ Measure Patient journey time-stamps –Waiting time from triage to time seen by a decision making clinician. –Continuous measure

4. 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.

5. A quote! Paul Bataldens quote “ Every system is designed to get the results it gets”.

6. 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!

7. Percentage of patients in each TC at MMH ATS 1 = 1% 100%TBS 0min ATS 2 = 12.7%80% TBS10min ATS 3 = 50.9 %75% TBS 30min ATS 4 = 34.1%70% TBS 60min ATS 5 = 1.8%70% TBS 120min

8. Data 2013 TC 1TC 2TC 3TC 4TC 5 Total10541300151995348451820 Tot admit7476438199948403171 % of TC admitted71%50%38%24%9% TC 1TC 2TC 3TC 4TC 5 Pass100%57%31%50%102%

9. Median/Mean Time TBS TC 1TC 2TC 3TC 4TC 5 0209410382Median 04081 78Std Deviation

10. MMH Performance TC 2 Target 80% seen 10min

11. Triage Cat 3 patients Target 75%seen in 30min

13. 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

14. 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.

15. 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?

16. 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