Navigating Triage to Meet

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June 2013 | Volume 21 | Number 3 EMERGENCY NURSE20

Art & science | patient assessment

Until two years ag he ma perfrmacemeasure fr emergecy deparmes (EDs)

Egad as he fur-hur ag me arge,

hch requred ha 98 per ce f paes ere

dscharged r admed ess ha fur hurs.

i Apr 2011, hever, as par f he nHS oucmes

Framerk (Deparme f Heah (DH) 2010),

hs sadard as repaced by a e se f cca

dcars measure he quay f care.

t f hese dcars sae ha, fr paes

h arrve a EDs by ambuace, he me a

assessme mus be ess ha 15 mues ad

he me a reame mus be ess ha

60 mues. these requremes affec h EDs

receve paes ad beg her reames.A paes seekg emergecy care are raged s

ha hse h he ms urge r fe hreaeg

cds ca be defed. the ms dey used

rage he UK s he Macheser trage Sysem

(MtS) (Mackay-Jes et al2008), hch Cke et al

(2000) fud as beg used by 75 per ce f UK

ED saff. over he ex decade, hs fgure rse

96 per ce (nee ad Smh 2008).

the MtS s based a agrhm cmprsg52 f chars ha refer paes preseg

cmpas. i each f char here are

sx key dscrmars:

lfe-hreaeg.

Haemrrhage.

Pa.

Cscusess eve.

temperaure.

Acuy f cd.

Afer chsg a dscrmar, rage urses assess

he urgecy h hch paes shud be reaed.

treames assessed be mmedae, urge

r rue are acaed he cur caegres red,

amber r ye, r gree respecvey (Gaeyad Gser 2011).

Meday nHS Fuda trus ED rduced he

MtS fr a assessme f a paes 1997.

over he ex seve years, aedace fgures a

he ED creased by abu 5,000 a year. Saff ere

spedg mre ad mre me assessg rue

caegry paes, hch as deayg defca

f paes h fe-hreaeg cds.

i 2004, herefre, a see ad rea, r sreamg,

sysem as rduced a saff defy

paes h mr cds he hey arrve

ad drec hem aay frm he rage queue. A s

f cds suabe fr sreamg as dra up

eabe recep saff regser hese paesaumacay befre hey ere dreced he

mr jures area.

Despe hs devepme, hever, prbems

h he use f MtS perssed. trage vved he

caegrsa f paes a cmpuer sysem

befre her cds had bee assessed, fr

exampe, hch mea ha her regsra k

prry ver care.

Inmaculada Diaz Alonso explains how the triage process

at her emergency department was replaced by a simpler

system in which nurses undertake initial assessments

navgag rage meearges fr ag mes

Correspondence

[email protected]

Inmaculada Diaz Alonso is clinical

nurse lead in the emergency

department at Medway

NHS Foundation Trust, Kent

Date of submission

January 22 2013

Date of acceptance

April 15 2013

Peer review

This article has been subject

to double-blind review and

has been checked using

antiplagiarism software

Author guidelines

www.emergencynurse.co.uk

AbsracAn initial assessment process, called navigation,

has been introduced at Medway Maritime Hospital

emergency department (ED) to address problems

with the triage system and to meet the latest ED

quality clinical indicators. This article explains

the rationale for introducing the new assessment

process, describes the system and discusses the

change-management process needed to implement it.

Keywords

Navigation, initial assessment, triage, streaming

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EMERGENCY NURSE June 2013 | Volume 21 | Number 3 21

Up 25 paes a hur regsered he

ED, h cmpuer rage akg a mmum f

15 mues cmplee fr each f hem. trage

urses had deal h a csa sream f self-

preseg paes r paes brugh byambulace ad fud dffcul keep p f

he rklad a peak mes.

ths resuled lg queues ad leghy ag

mes fr al assessme a busy perds, ad

rage urses sruggled defy ll paes

her arrval because hey had sped s much

me fr f he cmpuer, ryg clear he

backlg f paes.

there as fe a cflc beee he eed

fulfl rage caegres ad he requreme mee

he fur-hur ag mes arge, ad a balace

had be sruck beee aedg paes

h hgher rage caegres h had recely

arrved ad hse h ler caegres h hadbee ag lger.

Crary he releva naal isue fr

Healh ad Care Excellece (2012) gudeles, may

paes had a mre ha 30 mues be

see by urses. As a resul, cmplace h he nHS

oucmes Framerks (DH 2010) qualy dcars

fr al assessme became alms mpssble.

Agas hs backgrud, ad acpa f

he mme rduc f e qualy dcars,

he ser ursg eam he russ ED aalysed

rmal rage pracce ry defy h he

sysem culd be mprved. they als dre dagrams

f he emergecy care jureys made by paes

h self-prese ad hse h arrve by ambulace hghlgh flas he sysem.

Ms self-preseg paes regsered a

recep ad aed fr rage, alhugh hse h

mr jures ere sreamed he mr jures

u by recepss accrdg he clus

crera ls. ths mea ha admsrave saff

ere makg clcal decss abu sme paes

ad aalyss shed ha he recepss dd

alays dcae heher he paes cds

requred mmedae, urge r rue reame.

Because self-preseg paes had a

regser ad a aga fr rage, hey ere ulkely

be see by a urse fr a leas 30 mues. trage

self as a leghy ad me-csumg prcessbecause had be uderake a cmpuer

regardless f each paes cd.

Eve peple h had bee regsered errr,

r h requred smple advce, had be raged

s ha hey culd be dreced he apprprae

area. A he same me, rage urses ere expeced

carry u asks such as elecrcardgraphy ad

ure aalyss.

the ser ursg eam als fud ha, due

a lack f dcumea abu al erves

he ED, may rage urses hugh hey culd

, fr example, gve paes aalgesa ul hey

had bee regsered he sysem.whe paes arrved by ambulace he urse

charge f he ED as expeced uderake full

hadvers h ambulace saff befre makg

al assessmes. the urses charge f he

ED are bad 6 r 7, ad have suffce kledge

ad aumy make al assessmes ad

ae sme reames. i pracce, hever, full

hadvers rarely k place, ad he paes had

a fr rage ad al reames be carred

u by her, mre jur saff.

Paes ere he allcaed rlley spaces r

ake he ag rm, here hey aed be

regsered he cmpuer sysem, ad ere he

raged by eher he urse respsble fr he rlleyspaces r he rage urse he ag rm.

the ser ursg eam aalysg he sysem

ccluded ha cmpuer rage as lle mre

ha a admsrave exercse. Decs makg

shuld clude cgve, uve ad expereal

prcesses (Pugh 2002) bu, sead f drag

her experece ad u assg paes

rage caegres, may ursg saff ere assgg

e caegres he paes.

trage as ms fe effecve he as

uderake by ser urses, h have he

ecessary clcal sklls ad kledge.

Navigationthe ser ursg eam realsed ha urses eedls such as he MtS help hem make safe

ad effecve al assessmes, ad hey eed

cmpuers prcess he frma hey are gve

ad assg paes prry cdes.

the eam ccluded, herefre, ha he cause f

prblems he ED as he ay he MtS as beg

used, raher ha he sysem self, ad ha he ED

rage prcess shuld be smplfed ad prrse

pae care.

the ser ursg eam rked h her

ser saff develp a al-assessme

sysem ha uld vlve feer seps ha are

requred by he MtS ad hch urses, raherha -clcal saff, uld defy paes h

requre mmedae maageme r h shuld be

sreamed her areas.

ially, he eam apprached he iesve

Suppr team (iSt), par f he nHS ierm

Maageme ad Suppr (iMS) servce, hch

helps nHS rgasas chage clcal prcesses

(nHS iMS 2011).

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the iSts ma recmmeda was rduce

sreamg f paes her al assessmes

he ED. the eam he suded hw her hspals

Ke assessed ED paes her arrval ad

fud sme had pled sreamg sysems fr afew mhs bu had reured rage. oly e

hspal had cued sream paes bu had

als adped a cmpuer-based rage sysem. Raher

ha sreamlg he rage prcess, herefre, he

hspal had added a exra sep.

the seps vlved he MtS are shw

Fgure 1 ad hse vlved he ew sysem,

called avga, are shw Fgure 2. As hese

algrhms shw, he rduc f avga

has reduced he umber f seps requred befre

paes are see by decs-makg clcas,

whch has esured ur ha peple wh

lfe-hreaeg cds ca be defed earler.

i he avga sysem, paes wh prese he ED are assessed by a ser urse, called

a avgag urse, befre hey are regsered.

ths pracce esures ha lwer caegry paes

are sreamed by ser clcas raher ha -clcal saff, ad ha peple wh serus

cds ca be defed as s as hey

arrve a he ED.

navgag urses have he cmpeeces

rea pa by prescrbg ad admserg

aalgesa, ad rder vesgas as s as

paes arrve.

i each case, avgag urses recrd he resuls

f her assessmes, cludg basc bservas

ad descrps f he pahway each pae shuld

fllw, avgag frms. the avgag frmused a Medway Marme Hspal ED has bee

adaped fr Fgure 3.

the avgag frms are he passed

recep saff, wh regser he paes ad drec

hem he apprprae areas. they als sca ad

save he frms he releva paes elecrc

recrds s ha deals f he paes care pahways

are avalable saly clcas wh wrk all

areas f he ED.

Sme paes fllw pahways ha vlve

specfc vesgas, whch mus be carred u

befre decss abu he paes care ca be

made. these vesgas are made by aher

healhcare prfessal, called a avgagasssa, accrdg he prcples f he MtS.

the avgag asssa rle s, as far as he auhrs

kw, uque he rus.

Managing changeimplemea f he avga sysem requred

a chage pracce ad culure a he rus,

ad s success depeded careful plag

Figure 1 Steps involved in the Manchester Triage

System

Patient arrives by ambulance

Handover to nurse in charge

Patient allocated to waiting room or trolley space

Patient registration

Triage and prioritisation of care

Further investigations

Final relocation

Patient is seen by a clinician

Figure 2 Steps involved in navigation

Patient arrives by ambulance

Handover to nurse in charge. Prioritisation of

care according to patients clinical condition and

observations made during handover

Patient allocated to waiting room or trolley space

Further investigations

Patient is seen by a clinician

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Figure 3 Medway NHS Foundation Trust emergency department navigating form

Date .......................................................... Time ......................................................... Crew .......................................................

Name ......................................................... Date of birth ................................................ Navigator ..................................................

Navigator or ambulance handover details

Ambulance observations

Blood pressure Temperature Electrocardiography given? Yes No

Heart rate Body mass index Cannula given? Yes No

Respiratory rate Pupil size Pain score /10

Blood oxygen saturation Glasgow Coma Scale score

Medications and fluids given Time they were given

Navigator instructions

For navigation assistant? Yes No

Observations: have these been made? Bloods: have these been undertaken or assessed?

General observations Yes No Cannula Yes No Troponin I levels Yes No

Neurological observations Yes No Full blood count Yes No Paracetamol and salicylate Yes No

Electrocardiography result Yes No Urea and electrolyte test Yes No Beta HCG level Yes No

Ketone level Yes No International normalised ratio Yes No Progesterone Yes No

Body mass index Yes No Clotting Yes No Other tests

Urinalysis result Yes No Amylase level Yes No

Human chorionic gonadotropin

(HCG)

Yes No C-reactive protein level Yes No

X-ray result Yes No Liver function Yes No

Weight Yes No Glucose level Yes No

Treatment location

Priority number Ambulance overflow Emergency triage unit

trolley number

Trolley number GP majors Paediatricnavigator

Resuscitation number See and treat Paediatric trolley

Majors waiting room GP minors Paediatric see and treat

Pain score Drug Dosage Route Signature Given by Time

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and managemen of change. to gude he

change-managemen process, he senor nursng

eam adoped Koers (1995) egh-sep change

model. these seps nvolve:

1. Esablshng a sense of urgency.2. Formng a gudng coalon.

3. Creang a vson.

4. Communcang he vson.

5. Empowerng ohers o ac on he vson.

6. Plannng for and creang shor-erm wns.

7. Consoldang mprovemens and creang

more change.

8. insuonalsng new approaches.

Establishing a sense of urgency ths was

provded by he nroducon of new clncal qualy

ndcaors, as a resul of whch a new rage process

had o be compleed whn hree monhs.

Forming a guiding coalition Afer he senor

nursng eam had analysed he curren rage

process, presened s fndngs o senor ED ssers

and explaned why should be sreamlned. the

eam drew on advce from he iSt and senor ED

ssers, and s observaons of rage processes

a oher ses, o develop he navgaon sysem.

By nvolvng senor ssers a hs early sage,

Table 1 Most common staff questions and responses to them

Question Response

How do very ill patientsget flagged up in the

system?

New locations have been created in the computer system for flagging up patientsfor clinicians. When patients are registered, there is an option to place them in

a location, such as trolley 1, or in a priority location, such as priority trolley 1.

The patients remain in the same place but the change in the name of their locations

alerts clinicians to the higher priority of their care.

What happens when

there is no capacity for

patients who need to be

monitored?

This problem would be familiar to most emergency departments, regardless of the

type of initial assessment they use, and it should be discussed separately because

it does not form part of the navigation process. However, it is better to know that

patients require monitoring straight away rather than to find this out at triage,

when they will have been in the department for a while.

How do you record details

of patient assessments?

The navigating form is used for every patient and is scanned onto their electronic

records. The navigating room is next to the reception and, as soon as the navigating

nurses have completed their assessments, they put the forms in a tray to be collectedby reception staff, who then enter the details on the computer system. Details on the

form are entered on to the computer retrospectively and the time of initial assessment

by the navigating nurse is recorded as time of arrival.

Does recording the time

of assessment as time

of arrival constitute a

falsifying of records, given

the delay between them?

The delay between times of arrival and assessment is not taken into account because

assessment occurs almost as soon as patients arrive at the department.

What happens when there

is a queue for assessment?

Will patients wait longer?

Before navigation was implemented, patients queued to register at reception and

then for triage, so one queue has been eliminated. We know how many patients

are waiting for navigation because there is a marked off area in the waiting room

in which they can be counted easily. If there are more than five patients waiting forassessment, the navigating nurse alerts the nurse in charge, who assigns another

navigating nurse.

What happens if patients

need further investigations

before clinical decisions

can be made?

If patients conditions are thought to be life threatening, they are taken immediately

to a monitored bay. If they need full observations or diagnostic tests, they will be seen

by the navigating assistant, who can undertake on-the-spot, vital observations and

make quick decisions, for example to refer patients to GPs or discharge them.

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he eam esured hey had a sese f wershp

f he prjec, ad ecuraged hem egage

wh her eams hrughu he chage prcess.

Medway Hspal bard members were favur

f he chage he gruds ha wuld mprvepae experece ad help saff acheve he ew

qualy dcars.

Creating a vision the vs r ucme fr chage

was mprved pae safey ad sasfac.

Communicating the vision the vs was shared

all deparmeal eam meegs ad llusraed

psers placed he saff res rm. Feedback

ad sugges frms were als prvded s

ha saff culd share her deas ad ccers.

the ma ccers, ad eam members respses,

are descrbed table 1.

Empowering others to act on the vision the ser

ursg eam asked ser urses wh were

ehusasc abu he prjec becme avgag

champs, wh were respsble fr devsg

he avga frm ad leadg he pl prjec.

the ser ssers cduced research

aedace reds ad chse he quees day f

he week sar he pl.

Planning for and creating short-term wins

navga was regarded as a quck w, parly

because allws saff draw her clcal

experse durg al assessmes ad parly

because helps hem esure ha paeswh arrve by fr ambulace wa lger ha

15 mues fr assessme, as spulaed he

releva ew qualy dcar.

i add, all dagsc ess are carred u by

avgag asssas uder he avgag urses

srucs s, by he me paes are gve full

assessmes, he resuls f he al assessmes

have bee reured ad clcas ca make

decss mre quckly.

Consolidating improvements and creating more

change Chagg well-esablshed pracce ca

be prblemac ad, as chages pracce were

csldaed, varus prblems arse. Fr example,durg he pl prjec, he avgag urse greeed

paes as hey arrved he wag rm ad

aemped assess hem accrdg he kds f

frma ha, uder he ld sysem, hey wuld

have vlueered durg regsra.

ths pracce rased prvacy ad cfdealy

ssues, hwever, because he frma requred

by he avgag urse s mre dealed ha ha

Figure 4 Allocation of resources in navigation

One band 6 or 7

nurse in charge

One navigating nurseOne navigating

assistant

One resuscitation

nurse

Four trolley area

nurses

Two emergency

triage unit nurses

who work

from 11am

Two observation

ward nurses

Two minor injuries

nurse practitioners

One treatment nurse

usually vlueered recepss, ad paes

were reluca prvde such frma

whle amg her paes he wag rm.

ths prblem was vercme by remvg cmpuers

ad her equpme frm he ld rage rm,

ad cverg a avgag rm, wherepaes culd be assessed quckly ad prvae.

neverheless, may paes ad relaves dd

udersad he chage he rage prcess.

the MtS had bee place fr may years ad

paes geerally udersd ha hey wuld see

a urse afer hey had regsered a recep. Sme

were shcked be see by a urse arrval ad,

aferwards, were usure abu wheher hey had

bee assessed. ohers ssed preseg a

he recep desk raher ha beg see by he

avgag urse.

Durg hs perd, paes ad relaves

requred csa explaa ad reassurace,

ad a leafle descrbg he chage was draw upad gve hem her arrval, eher by he

avgag urse r recep saff.

the avgag frm has als bee chaged

accrdg requremes. A me f gg

press, he hrd vers f he frm s beg used

ad a furh vers, whch wll cver ssues such

as he maageme f peple wh have meal

healh prblems r wh requre clse mrg,

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References

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A&E: The Present State. Emergecy Medce

Research Group, Uverses of warck

ad Brmgham.

Department of Health (2010) A&E Clinical

Quality Indicators: Implementation

Guidance. yur.com/ousa69

(las accessed: May 23 2013.)

Ganley L, Gloster A (2011) A overve

of rage he emergecy deparme.

Nursing Standard. 26, 12, 49-56.

Kotter J (1995) leadg chage: hy

rasformao effors fa. Harvard

Business Review. yur.com/aqmqevc


Newell J, Smith P (2008) Triage in the

Light of Four Hour Targets: Results of

a Survey of Current Practice in Emergency

Departments in the UK. yur.com/p5g3465


Mackway-Jones K, Marsden J, Manchester

Triage Group (2008) Emergency Triage.

wey-Joes, Hoboke nJ.

NHS Interim Management and Support

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Emergency Care. yur.com/p4f92y8


National Institute for Health and

Care Excellence (2012) Quality

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Pugh D (2002) A pheomeoogc sudy of

fgh urses cca decso: makg

emergecy suaos. Air Medical Journal.

21, 2, 28-36.

s uder deveopme. ths verso aso ao

avgag urses o record assessmes of pae

rsk of abscodg so he urses charge ko

ho ofe efare checks shoud be carred ou.

whe rage as based o he MtS, ursesoud aed a orkshop o ear ho o uderake

rage ad ho o use he russ compuer sysem

o bud o her koedge. whe avgao

as roduced, hoever, he orkshops became

uecessary ad juor urses had o ay of

deveopg experece pae assessme.

to address hs probem, a cca prorsao

orkshop for juor urses as roduced.

As avgag asssas, juor urses are aso

expeced o ork aogsde avgag urses, ad

o ga experece hrough peer reve ad seor

suppor raher ha compuer program rag.

Institutionalising new approaches Aocao ofsaff he ED sce avgao as roduced s

sho Fgure 4. iay, saff ere re-aocaed

o he sysem, ahough oe exra urse as

subsequey hred o become a avgag asssa

o he gh shfs.

Durg he po ad afer avgao as

roduced, rage as based o he e sysem oy

durg he day ad urses coud rever o he more

famar MtS a gh.

Afer sx eeks, hoever, ursg saff decded

o adop avgao for 24 hours a day because

aoed hem o defy hgh rsk paes o

arrva, ad o make qucker ad safer assessmes.

ths decso o make avgao he esabshed

form of a assessme for he deparme as

cosdered a sg of success ad, november

2011, MtS as repaced by avgao he EDsoperaoa pocy.

Conclusion

navgao prorses a assessmes ad

esures ha he frs perso paes coac he

ED s a expereced urse. i aso reduces a

assessme me because does o rey o he use

of a compuer program, ad reduces he umber of

paes ho eed o be see by he avgag urse

by removg from queues hose paes ho have

arrved by ambuace. Paes are he sreamed

o he mos approprae areas from her arrva ad

hose h more urge eeds are defed more

qucky ad more effecvey.navgao s based ad rea o he prcpes

of rage, bu emaes exra seps. i aos

seor urses o dra o her experse ad heps

hem o defy hgh rsk paes a a eary

sage. A Meday Hospa ED, avgag urses

became beer abe o erac h paes afer

he deparmes compuersed assessme process

has bee removed.

Fay, maagg chage from a e-esabshed

sysem o a e cocep, ad esurg s vaby

ad success, requred carefu pag ad

mpemeao by he seor ursg eam.Conflict of interest

None declared

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C o p y r i g h t o f E m e r g e n c y N u r s e i s t h e p r o p e r t y o f R C N P u b l i s h i n g C o m p a n y a n d i t s c o n t e n t

m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a l i s t s e r v w i t h o u t t h e c o p y r i g h t

h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t , d o w n l o a d , o r e m a i l a r t i c l e s f o r

i n d i v i d u a l u s e .

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Navigating Triage to Meet