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PURPOSE: During an observational study, we investigated the potential benefits and risks of the use of admission and early transfer triage rules in 498 patients hospitalized with chest pain. PATIENTS AND METHODS: Appropriateness of triage decisions was measured using explicit and implicit judgments. RESULTS: Application of an admission triage rule (partially based on the Brush electrocardiographic criteria) would have increased coronary care unit (CCU) admissions by 3%, whereas application of a triage rule 24 hours after admission would have reduced bed utilization by 860 intermediate care and 82 CCU bed-days per year when compared with actual patient triage. Although 9.5% of patients who underwent triage according to the early transfer triage rule would have experienced a minor complication after transfer, the medical care of none would have been adversely affected. CONCLUSION: Our results show that application of a triage rule 24 hours after admission may have the potential to shorten length of stay in the CCU and intermediate care unit without significantly compromising patient care. However, use of the admission triage rule would have increased CCU bed utilization. The failure of the admission triage rule to improve bed utilization illustrates the potential hazards of ignoring patient complications, interventions, and co-morbidity when predicting the efficacy of a triage rule.
STUDY OBJECTIVE: To describe the Orange County trauma system's nine-year (July 1980 through June 1989) experience with patient triage. Changes in patterns were sought after the 1983 revisions in triage criteria. DESIGN: A nine-year retrospective analysis of trends in trauma patient triage in Orange County. A pre-analysis and postanalysis to discern changes in trends after a July 1983 revision in triage criteria was conducted. SETTING: Orange County, California, Emergency Medical Services (EMS) Agency, serving an urban population of more than 2 million. Orange County EMS responds to about 90,000 calls annually, 3,500 of which are for trauma patients. Twenty-eight nontrauma and neurosurgical paramedic receiving centers and four paramedic trauma receiving centers served the community during the study period. TYPE OF PARTICIPANTS: All patients triaged to Orange County trauma centers between July 1980 and June 1989. Single neurologic injury patients were triaged to neurosurgical receiving centers and are not included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Logarithmic regression analysis showed a 386% increase in the number of trauma patients triaged to trauma centers. The number of more seriously injured patients, as estimated by length of hospital stay of more than four days; Injury Severity Score of more than 15; fatality; or patients requiring surgery within six hours for trauma to the chest, abdomen, central nervous system, and/or major vessel, also increased. The rates of increase were more than those of the population (15%) for the Injury Severity Score of more than 15 group (79%) and the length of stay of more than four days group (108%), but lower for the fatality group (11%) and the early surgery group (7%). Because traffic and motor vehicle accidents comprise 70% to 80% of all trauma injuries, a separate analysis was conducted for these cases, using numbers of miles traveled as a basis for analysis. The analysis revealed a significant (alpha = .05) increase in over-triage rate, from 43% in 1981 to 74% in 1988, for motor vehicle accident patients. No changes in trends were found in the pre-analysis and postanalysis. Changes in trends occurred in 1986. CONCLUSION: The growth rate for the total trauma population exceeds that for overall county population growth. These results suggest overtriage. No changes in trends were found after the 1983 revisions in triage criteria. Changes in trends were found in 1986 after the revisions in the Injury Severity Score scoring system.
OBJECTIVE: To compare formal nurse triage with an informal prioritisation process for waiting times and patient satisfaction. SETTING: Accident and emergency department of a district general hospital in the midlands in 1990. DESIGN: Patients attending between 8:00 am and 9:00 pm over six weeks were grouped for analysis according to whether triage was operating at time of presentation and by their degree of urgency as assessed retrospectively by an accident and emergency consultant. PATIENTS: 5954 patients presenting over six weeks. MAIN OUTCOME MEASURES: Time waited between first attendance in the department and obtaining medical attention, and patient satisfaction measured by questionnaire. RESULTS: Complete data on waiting time were collected on 5037 patients (85%). Only 1213 of the 2515 (48%) patients presenting during the triage period were seen by a triage nurse. Patients in the triage group waited longer than those in the no triage group in all four retrospective priority categories, though differences were significant for only the two most urgent categories (difference in median waiting time 10.5 (95% confidence interval 3.5 to 14) min for category 1 and 8.5 (3 to 12) min for category 2). Responses to the patient satisfaction questionnaire were similar in the two groups except for the question relating to anxiety relating to pain. CONCLUSIONS: This study fails to show the benefits claimed for formal nurse triage. Nurse triage may impose additional delay for patient treatment, particularly among patients needing the most urgent attention.
A pilot study of the effectiveness of prehospital triage of trauma patients was carried out in a western Sydney between February and July 1988. Triage guidelines were developed to identify seriously injured persons at the incident site who might warrant admission to a Level 3 Trauma Service Hospital (Trauma Centre), as part of the NSW Department of Health trauma services plan. The study results were based on 64% of ambulance trauma transports for which a triage decision was provided. Of trauma transports studied, 3.7% had injuries serious enough to warrant admission to Level 3 Trauma Service Hospital. Ambulance officers correctly triaged 77% of these cases in the field. However, 62% of trauma transports triaged 'severe' or 'critical' did not have injuries serious enough to warrant admission to a Level 3 Trauma Service Hospital. Nevertheless, the triage guidelines compared favourably with similar instruments used elsewhere. Based on the performance of the triage guidelines it was concluded that the introduction of a regionalized trauma service in metropolitan NSW with local bypass is possible.
Triage nursing is evolving as a subspeciality of emergency nursing. Of the five major types of triage systems in use, four utilize nursing personnel. The Advanced Triage System is the most comprehensive system and is utilized in the Emergency Department at Harbor-UCLA Medical Center. This article defines the process of triage, reviews various types of triage systems and discusses the role of the triage nurse in the Advanced Triage System utilized at Harbor-UCLA Medical Center.
In the development of triage and bypass protocols, many different scoring systems and triage criteria are being used. Our purpose was to evaluate the Revised Trauma Index (RTI) as a triage tool for both its severity prediction ability and triage accuracy. A total of 2,340 trauma admissions were evaluated using the RTI and the Injury Severity Score (ISS). The data were submitted to standardized statistical analysis and compared to other published data for under and overtriage. Our results show a linear correlation between the RTI and the ISS with a correlation coefficient of .62. There is 5% death rate at an RTI level of 15, which yields a 5% undertriage rate for death and a 37.3% overtriage rate for predicting an ISS greater than 15. This compares to under and overtriage rates for the Trauma Score, CRAMS, Pre-Hospital Index, and Mechanism of Injury scales varying from 19% to 56% undertriage and 7% to 82% overtriage. We reached the following conclusions. a) The RTI is a simple, fast triage tool for predicting major trauma. b) The RTI is related to the ultimate ISS. c) Use of an RTI greater than or equal to 15 results in an acceptable undertriage rate, with a better rate for overtriage than existing scores. d) Therefore, we recommend the RTI for use in emergency medical direction and bypass protocols.
The concept of triage is central to the allocation of healthcare resources. As demands for health care increase, medical technologies and providers become more expensive and more scarce. Triage decisions occur at all levels in the distribution of resources. It is essential to explore the concept of triage and some of the underlying ethical principles for triage decision-making from the perspective of the discipline of nursing. Examining how definitions of triage apply to practice will enable nurses to participate in reform strategies for the healthcare system.
Although triage as a medical sorting process was originally developed and applied to echeloned military field medical systems dealing with mass casualties, the term has now permeated most aspects of medical practice. This essay attempts to refocus on triage in military and disaster settings, emphasizing the relationship of the echeloned system organization to the triage process, and the various non-medical factors which may influence triage decisions and priorities. Due to the lack of any analogous civilian experience, it is essential that all health personnel who may be involved in an echeloned care system gain and maintain proficiency by frequent involvement in appropriate training exercises, the characteristics of which are described.
The ability to assign patients to the most appropriate program of intervention would improve patient outcomes and reduce health care costs. This paper evaluates specific potentials of triaging patients into various combinations of health education treatments. Blood pressure improvement among hypertensive patients was measured and the associated treatment cost and savings were compared. Triaging rules were formed empirically from the relationship between patient characteristics selected before the study was conducted and their achieved blood pressure control within each combination of interventions. Patients randomly assigned to seven combinations of three interventions were studied in contrast to patients in a randomized control group. A combination of all three interventions was the most effective program for the undifferentiated (random) patient population, achieving a 49% increase over 18 months in patients with blood pressure under control. By triaging, 51-91% increases in patients with controlled blood pressure were achieved. Educational history of the patients which is a fairly reliable measure was the most efficient triaging variable, showing a 91% increase in patients with blood pressure under control and a relative cost saving of about 400%.
Triage skills are requisite for all providers of prehospital care. Methods of assessing the acquisition of triage skills vary in complexity and expense. In this study, 61 prehospital care providers classified 20 cases, divided into four groups of five cases each: moulaged live trauma victims, nonmoulaged live trauma victims, nonmoulaged manikin trauma victims, and written scenarios. The providers were asked to classify the cases in each group by assigning triage tags to indicate injury severity and to rank the trauma victims in each group according to the urgency of care required. Analysis of variance revealed statistically significant differences among the four methods in both mean tagging scores (F3,235 = 8.63, P less than .0001) and mean ranking scores (F3,232 = 6.09, P less than .001). Multiple comparisons using Scheffe's test revealed that the mean tagging and ranking scores for moulaged live victims and written scenario methods were comparable and that both were significantly superior to the scores of the two other methods. However, a qualitative evaluation revealed that the providers greatly preferred triage of moulaged live victims to the other three methods.
Because of severe emergency department (ED) overcrowding, the authors initiated a program of referring certain patients who were assessed as not needing emergency care away from the ED. A selected group of patients who presented to a busy university ED were refused treatment and triaged away following a medical screening examination performed by a nurse. In this 3-year study 136,794 patients presented to the triage area in the ED, of which 21,069 (15%) were refused care and referred elsewhere. Letters and calls to all referral clinics, eight local EDs, and the coroner's office identified no patients who had been grossly mistriaged, and only insignificant adverse outcomes could be identified. Additional follow-up on 3,740 individuals triaged away was performed by telephone. Responses from this survey indicated that 42% of persons received care elsewhere the same day, 37% within 2 days, and 22% decided not to seek medical care. A group of 1.6% sought care at other hospital EDs for minor complaints. The authors concluded that a group of patients can be selectively triaged out of the ED without significant adverse outcomes, which may offer one approach to the problem of ED overcrowding.
At Brooke Army Medical Center the Emergency Services Section has developed an algorith,-directed triage system to be used by "screeners" who may be basic medical corpsmen but sometimes have had no previous medical experience. After 25 hours of classroom and 120 hours of on-the-job training, the screeners use the algorithms to triage patients into one of three treatment areas in the emergency section or to clinics outside the emergency section during the day and evening. The screeners may consult with a triage physician if the algorithm-directed disposition appears inappropriate, Triage dispositions of 78,822 patient visits during the calendar year 1975 are presented.
A 9-month prospective study was conducted in Salt Lake County to evaluate the efficacy of a field trauma triage system using the CRAMS score. Before the triage system was implemented trauma victims were taken to the nearest appropriate hospital. Post-implementation, trauma victims with field CRAMS scores of 1 through 6 were triaged to the Level I Trauma Center. Of the 113 study patients, 53 were in the pre-implementation phase and 60 in the post-implementation phase. The study patients with CRAMS scores of 4 or less had lower mortality when cared for at the Level I Trauma Center (p = 0.013). We conclude that trauma patients who are severely injured (CRAMS less than or equal to 4) have a significantly higher rate of survival if taken to the Level I Trauma Center. The use of the CRAMS triage system appears to be an effective approach toward improving trauma care in Salt Lake County.
This study was carried out to investigate the effect of triage on attenders' waiting times in an accident and emergency (A & E) department. The A & E department comprised three separate areas: the A & E unit, dressing clinic and review clinic. Data on all A & E attenders were collected by the nursing staff over a period of 1 week using a data collection form. The waiting times for the attenders to be seen by a doctor in 1988 were longer than in 1986. This may partly reflect the lower number of people using A & E in 1986, while the current practice of an initial triage assessment may slow the patients' access to a doctor. This latter finding is a cause for concern, since the receptionist is the main triage assessor at night. However, the time the attender spent waiting to be clinically assessed by a health care professional (nurse) was shorter in 1988 than when performed by a health care professional (doctor) in 1986. This indicated that nurse triage enabled a shorter waiting time between arrival and assessment of the A & E unit attender.
This study describes the complexity of the telephone-triage task in a community-based AIDS clinic. We identify deficiencies related to the data management for and documentation of the telephone-triage encounter, including inaccessibility of the medical record and failure to document required data elements. Our needs analysis suggests five design criteria for a computer-based system that assists nurses with the telephone-triage task: (1) online accessibility of the medical record, (2) ability to move among modules of the medical record and the triage-encounter module, (3) ease of data entry, (4) compliance with standards for documentation, and (5) notification of the primary-care physician in an appropriate and timely manner.
Field triage of injured patients has the objective of rapid identification of that 5-10% with injuries serious enough to pose a risk to life. The process requires not only the identification of patients with abnormal physiology, but also those whose physiology is normal despite the fact that significant anatomic injury may exist. This paper defines relationships by which vehicle damage information available at the accident may augment the physiologic measures used for triage decisions. Vehicle velocity changes of 20 m.p.h. or more in direct frontal collisions, 22 m.p.h. or more in offset frontal collisions, and 15 m.p.h. or more in side impacts captured 90% of the patients with Injury Severity Scores of 16 or greater. The amount of vehicle damage observed with these velocity changes was found to be 20 inches of crush in direct frontal collisions, 28 inches of crush in offset frontal collisions, and 15 inches of damage in side impacts. Incorporating these findings into triage of trauma patients who exhibit normal vital signs at the accident scene may provide a more structured basis for field triage.
Organizations prepared to respond to war, fire, flood, earthquake, or attack are essential for effective disaster control. "Valley Triage" the San Fernando Valley Medical Triage Team in Los Angeles, was formed to meet this need. The team is a mobile medical unit staffed by physicians and coordinated with civilian and military emergency services. It incorporates innovative means of communication, transportation, equipment, and training. The primary aim of Valley Triage is to provide on-site medical attention to disaster victims, and to coordinate their transfer to adequately staffed and equipped hospitals. Valley Triage offers a new approach to disaster management and can serve as a model for the development of other teams throughout the nation.