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DO WE NEED TRIAGE?
Author: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, Lexington, KYSection Editors: Andi L. Foley, MSN, RN, CEN, and Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN
Emergency nurses inherently believe that we needtriage to prioritize patients. Using triage as a processto sort patients is appropriate. However, in many
facilities, triage has evolved over time into a place asopposed to a process. Triage has become a sacred cow inmany emergency departments. When triage is a placewhere patients must stop, bottlenecks may occur, resultingin an increased length of stay. In an environment where thefocus is on safety and efficiency, triage as a place should nolonger occur.
Triage as a process can be the driver that enhancesoverall throughput. Patients come to the emergency depart-ment to see a provider. Processes that inherently slow pre-sentation to provider time may compromise safety, as wellas patient and staff satisfaction. Traditional triage as a placedoes not facilitate getting the patient to the providerquickly. Many solutions have been attempted to reducedoor-to-provider times: bedside registration, immediatebedding, emergency departments without waiting rooms,and keeping patients vertical. Although some time gainsmay be achieved by using these solutions, these same stra-tegies could prove to be ineffective. What changes need tooccur to minimize delays from presentation to provider?
The triage nurse needs to know about the populationthat presents to the emergency department. When willpatients arrive, how many will arrive at a time, how manywill arrive per hour, and how sick will they be? Each facilityhas these data, and they should be used to allocateresources so that patients do not end up in a queue atthe front end waiting to be seen. As emergency nurses,we have an obligation to ensure that triage is a true sortingof those who are sick from those who are not sick. Personswho are sick should be taken immediately to a treatment
area, and those not as sick may go to an intake area. Assess-ment and care provided in the intake area should includedocumentation of the chief complaint and vital signs.Every patient does not need a bed. Keeping low-acuitypatients vertical or in a chair setting for care will decreaselength of stay and optimize efficiency.
We don’t really need triage—at least, not triage as aplace. For triage as a process to be effective, the walls oftriage must go away. Care processes traditionally associatedwith triage can be done at the sides of stretchers or chairs asthe patient’s condition dictates. The initial encounter withthe patient should include a “quick look.” The emergencynurse’s first assessment of the patient’s appearance gatherssufficient information when combined with the stated chiefcomplaint to determine the appropriateness of use of astretcher or chair in the intake area.
How do we remove the barriers of triage as a place? Itis essential that a team of stakeholders with ownership inthe current triage process work together. These stake-holders include nursing, registration, greeters, providers,and administration, at a minimum. Once the team is estab-lished, begin by looking at current processes to identifyevery step in the patient’s trajectory through the ED visit.Enlist the help of “lean teams” or simulation to determinewhere silos or delays in getting the patient to a care provi-der exist. Identifying delays leads to rapid-cycle testing ofsolutions to eliminate delays. Team members need to bewilling to submit any potential solutions to a trial. No areasare off limits. The goal must be to eliminate causes ofdelays in getting the patient to the care provider.
Triage evolved to a place over time. In battlefields,where the concept of triage developed, triage did not occurin any particular location other than where the patientswere found. Returning triage to a process that occurs inany location that most rapidly facilitates getting the patientto the care provider for definitive care is the right approachfor safety and the right approach to ensure that the patienthas the best possible outcome.
Submissions to this column are encouraged and may be sent toAndi L. Foley, MSN, RN, [email protected] Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, [email protected]
Patricia Kunz Howard, Member, Bluegrass Chapter, is Operations Manager,Emergency and Trauma Services, University of Kentucky Chandler MedicalCenter, Lexington, KY.
For correspondence, write: Patricia Kunz Howard, PhD, RN, CEN, CPEN,NE-BC, FAEN, 2108 Thorndale Way, Lexington, KY 40515; E-mail:[email protected].
J Emerg Nurs 2011;37:597.
Available online 9 September 2011.
0099-1767/$36.00
Copyright © 2011 Emergency Nurses Association. Published by Elsevier.All rights reserved.
doi: 10.1016/j.jen.2011.08.008
T R I A G E D E C I S I O N S
November 2011 VOLUME 37 • ISSUE 6 WWW.JENONLINE.ORG 597
