Evaluation of Emergency Room Triage Performed by Nurses

Evaluation of Emergency Room Triage Performed by Nurses SUSAN L. ALBIN, MS SYLVIA WASSERTHEIL-SMOLLER, PhD SHELDON JACOBSON, MD BERTRAND BELL, MD An evaluation of the nurse triage system at a large municipal hospital's emergency room is presented. Introduction The system of emergency room triage, which has been in use for some time in busy urban hospitals, is a possible Many publications over the past few years have docu- solution for dealing with the problem. Weinerman describes mented the fact that metropolitan hospital emergency the triage function: "To provide immediate brief medical rooms are faced with the problem of treating the full evaluation of all incoming patients, determination of the spectrum of health care needs, ranging from routine pri- general nature of the problem, the trend of service needed mary care to dramatic medical emergencies. Studies sug- and the appropriate referral." gest that one-third to one-half of the patients who use Traditionally, the triage decision is made by a emergency rooms can be classified as having non-urgent physician,2. 12 but nurses have also done emergency room conditions. 1-11 In a study by Weinerman, 25 per cent of the triage. 13-7 interviewed subsample considered the emergency room as At the Bronx Municipal Hospital Center (BMHC) over their usual source of medical care.2 Clearly, the increasing 50,000 patients are triaged each year by specially trained use of emergency rooms for primary care reflects a com- triage nurse professionals. A study was undertaken in 1972 munity need for medical facilities. and 1973 to evaluate the functioning of the nurse triage The emergency room, however, or any one facility system at the Bronx Municipal Hospital Center. cannot effectively respond to this full range of needs. Rendering primary care in an emergency room setting is more costly in terms of equipment and personnel-and Training of the Triage Nurse many problems are better handled in a more relaxed atmosphere. Also, an overload of non-emergency cases may The emergency room triage nurses at the Bronx Munic- result in increased and unacceptable delays in rendering ipal Hospital Center were trained only after a minimum of 1 prompt care to true emergencies. year of general experience in emergency nursing with a minimum of 3 months of emergency room experience at our Ms. Albin is an Associate and Dr. Wassertheil-Smoller is an institution. Associate Professor in the Department of Community Health, The formal training program consisted of a series of Albert Einstein College of Medicine, Yeshiva University, Bronx, com- New York 10461. Dr. Jacobson is Director of Emergency Services 32 lectures covering the common presenting chief and Dr. Bell is Director of Ambulatory Care, Bronx Municipal plaints as determined by a preliminary survey. Hospital Center, Bronx, New York 10461. This paper was presented These talks centered about the differential diagnosis of at the 101st annual meeting of the American Public HIealth the presenting complaint concentrating on prognostically Association, November, 1973, in San Francisco, California, and serious entities. For each there was a brief review of revised September, 1974. This research was funded by the New entity York Metropolitan Regional Medical Program. Requests for re- the normal physiology and pathophysiology. In addition, prints should be addressed to Dr. Wassertheil-Smoller. pertinent physical findings were discussed and demon- EMERGENCY ROOM TRIAGE 1063 strated. Finally, each diagnostic decision was weighed go to some facility at BMHC for treatment. None of these according to a system of triage notations as follows: patients were admitted to BMHC within the succeeding 3 months. Of the 50 patients sent out of the hospital, 27 were Definition of Triage Classification successfully contacted by telephone or mail. I A patient with a life-threatening emergent problem The procedure for evaluating the chart was as follows: IA Must be seen by the emergency room physician There were four physicians who participated in the evalua- IB Can safely wait up to 2 hr for emergency treatment tion. All were working in hospitals other than BMHC. Prior II A patient with an urgent problem, although not life- to the evaluation, the physicians were given information threatening, but has the potential for becoming so, if about the functioning and the facilities available for treat- not treated expeditiously ment. IIA Must be seen on the same day of presentation always- Each chart was reviewed by two physicians from the emergency room panel of four. The physicians were required to independ- not necessarily in the the IIB Must be seen within 5 days in the appropriate outpa- ently fill out a questionnaire using the information from patient's chart and the triage slip which contained informa- tient department area The III Patients with chronic, minor, or psychosomatic com- tion on the presenting symptom and triage decision. as availa- charts were in various degrees of completeness, accuracy, plaints should receive a routine clinic referral The key ble and neatness, as is the case in a busy hospital. the nurses question on the evaluation form was: "Knowing all the During the didactic portion of their training, should have been gained practical experience by spending time each day facts, where do you think the patient as performed by senior emer- seen?" observing the triage process did not agree on the answer to the gency room personnel. The final 6 weeks of their training If the two physicians triage key question, a third independent evaluation was done by consisted of graduated independence in making to break the tie. the supervision of senior emergency room one of the remaining two physicians, decisions under The physicians were asked to make their decision personnel. concerning the appropriate disposition based on outcome The entire training program was carried out on a rather than on process of 3 months. variables, such as final diagnosis, half-time basis over a period variables, such as diagnostic techniques used. Other information about the final disposition of the Methodology of Evaluation Study patient after treatment and about triage nurse-patient At the Bronx Municipal Hospital Center, the triage communication was also collected. nurse, seated in the entrance to the emergency room, Auxiliary studies on presenting symptoms and nurses' routinely evaluates each patient who wishes to be seen and attitudes were also performed. completes a "triage slip," specifying the patient's name, complaint, and the facility to which he must go for Results treatment. During the study period, January, 1973, a copy Distribution of Triage Decisions of each triage slip and additional information identifying the patient were collected for the equivalent of 2 weeks. The It was found that 43 per cent of the patients who came design appropriately reflected the days of the week and to the emergency room were triaged to be treated in the various shifts. Data were collected only during hours when emergency room. Forty-six per cent of the patients were sent the screening clinic was open (8 a.m. to 9 p.m. daily); during to the screening clinic, which is a general medical walk-in the night hours significant triage options were not available. clinic, and 8 per cent were sent to outpatient specialty A sample of 500 was chosen from the 2003 triage slips, clinics. The data were collected during hours when the using a table of random numbers. The sample was stratified screening clinic was open. This compares favorably with by triage disposition, i.e., the treatment facility that the findings from other studies, previously mentioned, where 50 triage nurse had decided upon, as follows: 100 patients sent to 60 per cent of the cases seen in the emergency room were to the emergency room; 250 patients sent to the general reported non-urgent. medical walk-in clinic; 100 patients sent to a particular A prestudy had been conducted 4 months earlier and specialty outpatient clinic; and 50 patients sent to facil- similar results were obtained at that time, as shown in ities outside BMHC (Board of Health or the municipal Table 1. in the home district). hospital patient's Evaluation Results A pre-study had been conducted to determine the relative percentages of the groups. The study sample was The following definitions were employed. A correct stratified in these proportions so that there would be an triage decision was one in which two evaluating physicians adequate representation for each group. When appropriate, agreed that the patient would receive the most appropriate the figures presented here will be weighted to reflect the care at the facility to which the nurse had sent the patient. actual population that was triaged. A mistriage occurred when two evaluating physicians Of the 450 patients seen in BMHC 360 (75 per cent) of agreed that the patient's condition was an emergency and the charts were located. Telephone follow-up suggests that should have been treated in the emergency room as opposed 90 per cent of the patients whose charts were not located did to the screening clinic or two evaluating physicians agreed 1064 AJPH OCTOBER, 1975, Vol. 65. No. 10 that the patient had to be seen by a doctor on the same day For example, one patient complaining of a sore throat and as opposed to being sent home with an appointment for the cold was given an appointment to the screening clinic for next day. An uptriage was a case in which two evaluating the next day. The evaluators believed the patient should physicians agreed that a patient seen in the emergency room have been seen the same day, despite the overcrowding in had a condition which was not an emergency and that the the screening clinic. When he returned the following day he patient could have received good care in the screening was seen, treated, and released.

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