Mandatory Triage Does Not Identify High-Acuity Patients Within Recommended Time Frames

doi:10.1016/j.annemergmed.2011.02.001

Annals of Emergency Medicine

Volume 58, Issue 2, August 2011, Pages 137-142

Presented as an abstract at the Society for Academic Emergency Medicine Western Regional Meeting, March 2010, Napa, CA; the Society for Academic Emergency Medicine Annual Meeting, June 2010, Phoenix, AZ; and the UK College of Emergency Medicine meeting, September 2010, Birmingham, England.

https://doi.org/10.1016/j.annemergmed.2011.02.001 Get rights and content

Study objective

We determine whether mandatory formal triage of walk-in emergency department (ED) patients provides timely recognition of the most acutely ill.

Methods

This retrospective cross-sectional study was conducted at a US urban academic ED, annual census 39,000, which uses Emergency Severity Index-5 triage (ESI-5) for all arriving patients. ESI-5 recommends that level 1 and 2 patients be treated by a physician immediately or within 10 minutes, respectively. For all high-acuity (ESI 1 or 2) patients presenting between January 1 and December 31, 2008, data from electronic medical records and registration and tracking systems were used to determine elapsed time from arrival to completion of triage (median, range, 95th percentile), proportion of these intervals that met ESI-5 recommendations, and whether triage throughput differed during peak arrival hours.

Results

For 3,932 high-acuity walk-in visits (ESI 1=63; ESI 2=3,869), median time from arrival to triage completion was 12.3 minutes, range 0 to 128 minutes. Twenty-seven percent (95% confidence interval [CI] 26% to 29%) of high-acuity patients were taken to rooms on arrival; 41% (95% CI 40%, 43%), including those roomed immediately, completed triage within 10 minutes. Twenty-five percent (95% CI 24% to 26%) completed triage in greater than 20 minutes and 10% (95% CI 9% to 11%) greater than 30 minutes after arrival. Between 10 am and 10 pm (peak arrival hours), triage took longer for level 2 patients, and fewer met ESI recommendations.

Conclusion

Less than half of high-acuity patients in this urban ED completed triage within time frames recommended by the ESI-5, resulting in potentially unsafe delays. Although mandatory formal triage theoretically identifies patients who should be treated most quickly, the value and safety of this process should be reassessed.

Introduction

Most US emergency departments (EDs) use a structured triage process for all walk-in patients. Mandatory triage, regardless of patient age or chief complaint, is thought necessary to quickly identify acutely ill patients, especially during the busiest periods. In England, formal triage of all walk-in ED patients is considered a source of delay and was largely abandoned after 2005 as part of sweeping process changes introduced to meet a 4-hour emergency throughput target.1, 2, 3 Although the changes in England would seem unsafe, to our knowledge there is no published evidence demonstrating whether mandatory triage as implemented in the United States actually results in timely recognition of most high-acuity patients or how timeliness is affected during busier periods.

ED physicians and nurses rely on triage during busy times to identify patients who need to be treated quickly; a great deal of nursing effort is devoted to this endeavor. As we consider ways to streamline operations, reduce waiting time for patients, and prudently use health care resources, we should evaluate the value added by triage.4, 5 Even more important, for patient well-being, we should determine whether triage creates a safety net as intended and adjust our procedures if data prove otherwise.

We undertook a study to determine the proportion of level 1 and 2 (hereafter, “high-acuity”) walk-in patients who are identified within the time frame recommended by the Emergency Severity Index (ESI), a 5-tier (ESI-5) triage scoring system used widely in the United States, and whether this performance is different during peak arrival hours. ESI-5 recommends that level 1 patients be treated by a physician on arrival to the ED and level 2 patients be treated within 10 minutes.⁶

Section snippets

Study Design and Setting

This was a retrospective cross-sectional study of ambulatory patients presenting to the ED of a US urban, academic, tertiary care hospital. The ED has an annual census of approximately 39,000 adult and pediatric patients, and approximately 15% arrive by ambulance. Greeter nurses briefly screen walk-in patients on arrival and enter their names and chief complaint in a computerized arrival log with an automatic time stamp for “greet time.” If the greeter nurse recognizes that the patient has an

Results

We identified 3,949 high-acuity visits for patients who did not arrive by ambulance. Seventeen of these visits did not have a verifiable triage date and time, leaving 3,932 high-acuity visits for analysis. Sixty-three visits were ESI 1 and 3,869 were ESI 2. For the high-acuity group as a whole, median interval from arrival to triage completion was 12.3 minutes, with a range of 0 to 128 minutes and 95th percentile of 38.6 minutes (Table). Twenty-seven percent (95% CI 26% to 29%) of high-acuity

Limitations

This study was conducted in a single institution. At a tertiary care hospital in a multicultural urban environment, triage may take longer because of complicated medical histories and language barriers. Additionally, the triage arrangement may not match that of other EDs. We did not determine whether patients should have been categorized as level 1 or 2; the aim of our study was only to determine whether patients with this designation complete triage within the recommended time period.

Discussion

Our study found that less than half of high-acuity patients completed triage within 10 minutes of arrival to the ED. During busier times, the time from arrival to completion of triage increased further. Although the ESI does not address the time frame for completion of triage, it does recommend time frames within which providers should treat patients. If patients are undergoing triage in a separate area, as is the case in most EDs, then they are not available to providers. In our study, we

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Cited by (16)

Factors influencing door-to-triage- and triage-to-patient administration-time
2022, Australasian Emergency Care
Citation Excerpt :
Waiting times of more than 10 min to be triaged are frequently encountered, especially during busy hours of an ED [7,14]. One study found that not even 50% of the high-acuity patients were treated by emergency physicians within the time frames recommended by the ESI-guidelines [15]. Our study adds to the existing data on waiting times in the ED by analyzing the distinct influence of factors such as day of the week, frequency of patients with high priority and those brought in by ambulance.
Overcrowding decreases quality of care. Triage and patient administration are possible bottlenecks. We aimed to identify factors influencing door-to-triage- and triage-to-patient administration-time in a prospective observational study at a tertiary care center with 70,000 patients per year.
Measurement of aforementioned times at convenience-sampled time intervals on 16 days. Linear regression modelling with times as dependent variable, and demographic, medical and structural factors as covariables, testing for interactions with risk factor “weekend”.
We included 360 patients (183 female (51%)). Median door-to-triage-time was 6 (IQR 3–11) minutes, triage-to-patient administration-time was 5 (IQR 3–8) minutes. Overall door-to-triage-time was significantly shorter during weekends compared to weekdays (absolute difference 3 (IQR 1–7) minutes; 5 (IQR 3–8) vs. 8 (IQR 4–15) minutes, p < 0.01). Other influencing factors were closing hours of non-emergency department healthcare facilities (3.5 min more), number of ESI 2 patients seen during the interval (3 min more for each patient per hour), and ambulance activity (2 min more for each patient per hour brought by ambulance).
Day of time and week as well as frequency of patients with urgent conditions and those brought by ambulance significantly increased door-to-triage times. This should be kept in mind when organizing ED workflow.
Triage, Machine Learning, Algorithms, and Becoming the Borg
2018, Annals of Emergency Medicine
A Systematic Approach to Evaluation of Performance Deficiencies in ED Triage
2017, Journal of Emergency Nursing
Citation Excerpt :
The panel found that the ED staff was not aware of potentially high-acuity patients presenting to the registration clerk until they were triaged, which could contribute to wait times exceeding the recommended durations for patients with more urgent needs. The observed results were consistent with those reported by Weber et al,5 who found that high-acuity patients frequently did not receive care within the recommended time frames based on the Canadian and Australasian Scales.3–5 They also reported that the experience and knowledge levels of the triage RN were critical factors in accurate triage and noted that triage-to-provider times were dependent on the number of RNs assigned to each shift, time of day, and number of patients awaiting beds in the emergency department.
• Nurses are uniquely situated to critically evaluate quality and performance measures, identify opportunities for improvement, and recommend potential corrective inverventions within the emergency department.
• Nurses can actively contribute to performance improvements that increase quality of care, improve patient outcomes and satisfaction, and reduce institutional liability and risk.
• Establishment of a systematic process to identify deficiencies, evaluate problems, and develop solutions is vital to continuous quality improvement.
Increasing ED crowding has resulted in greater demand and longer time-to-triage and time-to-provider wait times, making accurate triage more important than ever before to avoid poor patient outcomes and possible hospital liability. In one case, a 75-year-old patient presenting with chest pain became unconscious in the ED waiting area after initial registration but before triage. Although resuscitation was attempted, the patient did not survive. Continuous assessment and improvement are needed to streamline the triage process and improve accuracy and efficiency. Because nurses play a vital role in patient triage, they are uniquely positioned to evaluate and enhance the process.
When staff at an 18-bed emergency department in a rural hospital suspected potential quality deficiencies related to extended wait times and patients leaving without being seen, a panel of nurses was formed to characterize the problem by conducting a chart review to develop potential solutions.
The chart review identified a correlation between wait times and patients leaving without being seen during hours of peak demand. Accordingly, the panel collaborated and proposed several interventions to alleviate these problems.
Formation of a panel of skilled nurses to assess problems and recommend potential solutions may represent a useful approach for active nurse participation in quality improvement in the emergency department, thus having a meaningful impact on patient outcomes and hospital liability.
The performance limits of traditional triage
2011, Annals of Emergency Medicine
A determination of emergency department pre-Triage times in patients not arriving by ambulance compared to widely used guideline recommendations
2017, Canadian Journal of Emergency Medicine
NO WAIT: new organised well-adapted immediate triage: A lean improvement project
2021, BMJ Open Quality

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: Supervising editor: Donald M. Yealy, MD

: By Annals policy, submissions authored by faculty in the department of the editor in chief (Dr. Callaham) are handled entirely by other senior editors, and Dr. Callaham plays no role in their decision making nor is informed of any details during the process.

: Author contributions: EJW conceived and designed the study, and was responsible for study supervision. IM and EJW were responsible for collecting and cleaning the data. BG was responsible for designing and conducting the data analyses. All authors were responsible for data interpretation and writing the article, had full access to all the data in the study, and take responsibility for the integrity of the data and the accuracy of the data analysis. EJW takes responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Funding for statistical consultation was provided through a grant from the Academic Senate of the University of California.

: Please see page 138 for the Editor's Capsule Summary of this article.

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: Publication date: Available online April 23, 2011.

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The practice of emergency medicine/original researchMandatory Triage Does Not Identify High-Acuity Patients Within Recommended Time Frames

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design and Setting

Results

Limitations

Discussion

J Emerg Nurs

J Emerg Nurs

The impact of process re-engineering on patient throughput in emergency departments in the UK

Int J Emerg Med

Reducing Attendances and Waits in Emergency Departments: A Systematic Review of Present Innovations

Emergency Services Collaborative

Exploring new intake models for the emergency department

Am J Med Qual

Optimizing emergency department front-end operations

Ann Emerg Med

Reliability and validity of a new five-level triage instrument

Acad Emerg Med

The practice of emergency medicine/original research
Mandatory Triage Does Not Identify High-Acuity Patients Within Recommended Time Frames