The Art of Triage Christy Michael, BVMS Dovelewis Annual Conference Speaker Notes

The Art of Triage Christy Michael, BVMS DoveLewis Annual Conference Speaker Notes

Introduction

Triage systems were first developed by battle surgeons under Napoleon’s reign, first documented somewhere around 1792. Initially, systems were devised for use in military endeavors to help sort and prioritize surgical patients for transportation. In the early 1900s these systems evolved a bit and began to incorporate field stabilization in those cases where it was applicable.

In modern human healthcare systems, triage occurs at every level of care from an initial telephone contact to arrival at a health care facility. These systems face a particular challenge because they have to factor in not just traumatic injury but also a variety of illnesses and a variety of patient types (rather than a patient population consisting almost entirely of young to middle aged men). (Robertson-Steel 2006)

Triage Systems

There are quite a few human triage systems, most of which put people into categories based on easily identifiable severity of injury or illness. These are most commonly used in mass casualty situations but also used to some degree in modern hospitals where an influx of patients can quickly turn an emergency department into something that looks very much like a mass casualty incident. These patients are prioritized in some fashion similar to this:

• Patients requiring immediate intervention (red) • Patients that need care but will be okay if that care is delayed (yellow) • Patients that have minor injuries that merit treatment but will be okay if treatment is significantly delayed or not provided (green) • Deceased patients (black)

Ultimately, there is more to triage than just categorizing a patient into one of three or four treatment groups and giving them a tag or assigning them a color code. In 2011 the CDC published results of multiple studies that determined the impact of field triage of patients to an appropriate facility for the type of injury or illness they were suffering upon survival.

Sasser et al found that there was a 25% reduction in mortality when patients that were severely injured were appropriately transported to a level 1 trauma center and that there was a 24% increased mortality for those that were severely injured but under triaged to non-trauma centers. The recommendation for assigning a patient a category considered more serious were through a four step flow chart. The following patients would be considered more critical and require higher level of intervention:

• Patients with abnormal vitals or mentation • Obvious fractures, penetrating wounds, paralysis, crushed/degloved/mangled extremity, or amputation proximal to wrist or ankle • Significant falls and high risk automobile or motorcycle crashes • Age related factors, burns, advanced pregnancy, time sensitive extremity injuries, or because it felt like the right thing for the responder to do

Until we have more rigorous information about specific veterinary triage systems, our task as veterinary professionals is to utilize the information that we can from human medicine to improve our ability to provide care for our patients. The best study of a standardized triage system was published in JVECC in 2012 (Ruys et al) established that attempting to directly correlate a human style triage system to animals did slightly improve categorization of veterinary patients but noted that at least abbreviated patient examination and training were necessary. Other papers that have been published rely upon clinical chemistry results as part of the triage system and this is not particularly helpful in a clinical setting – if patients have already had blood work done then they probably have already had a full physical examination!

Pending development of those validated systems, we are best served by using a permutation of the CDC’s guidelines that help first responders make decisions about whether their patients should be directed to a level 1 trauma center or whether a non- trauma facility is appropriate. The goal of these triage guidelines in human medicine is ultimately to direct patient care to the most appropriate resources and avoid overloading one set of health care providers. For us, all of our patients are staying within our facility currently but a form of the guidelines the CDC has provided will help the triage professional understand which patients are in greater need within the confines of our hospitals.

Veterinary conversion of the CDC’s step-wise case for identifying patients with greater need:

• Physiologic Criteria: Abnormal vitals or mentation o Mentation without stimulation and with interaction can be assessed o Abnormal heart rate, mucous membrane color, pulse intensity can be identified with briefest of direct patient interaction

o Alterations in respiratory rate and effort can be stress related but should not be simply dismissed pending full physical examination

• Anatomic Criteria: Obvious fractures or severe injuries o Often these can be visualized immediately or these patients will be non- ambulatory and require stretcher or gurney transportation into the hospital o For those with hidden injuries, questioning the owner about the presenting complaint should trigger them to show you an injury. An axillary or chest penetrating injury can often be hidden and the patient may show no other signs of distress o In some cases superficial injuries without underlying deformity or ongoing hemorrhage can be bandaged for protection pending full physical examination o Even if there are no obvious injuries, if a patient appears painful, more emergent triage should be considered to hasten examination and administration of analgesia

• Mechanism of Injury Criteria: o Patients whose owners report a fall or vehicular trauma are excellent examples of patients in veterinary medicine that should be assessed promptly in a more intensive manner than that done in a base triage o Even if these patients are triaged to a treatment area for brief assessment by a veterinarian, checking blood pressure, temperature, and thoracic auscultation they can be returned to their owner if they are indeed stable but injuries in these cases can be insidious

• Special Considerations: o Recent toxin ingestion requiring prompt intervention – your clinic may want to have a list of toxins to triage directly to critical status, those that are stable and any not on the list should contact an animal poison control service while awaiting examination o Young to middle aged male cats straining to do anything in a litter box are high risk for urethral obstruction and should be rapidly assessed o Deep chested, large breed dogs retching, bloated, painful, or anxious o Acute onset abdominal distension o Pain o Active seizure

o This list in particular could be adjusted to cater to the demographics and needs of your practice. For example, at DoveLewis all guinea pigs and rabbits are triaged immediately to the treatment area to hasten their treatment. Our lobby is often an excessively stressful environment for these species so to reduce mortalities, all are triaged as critical regardless of their symptoms. Your clinic may want every diabetic that is not eating to be triaged immediately as critical and it is fair to set up that guideline internally. o Because the individual completing triage feels like a patient might be more critical than they look for no easily explainable reason

This sounds like a lot of work. How much time should be invested in this triage? Really the information collected here is fairly concise and much can be collected even as you walk toward an owner and patient, visually assessing for age, disability, visible injury, mentation, and respiratory pattern to start. A few quick questions are ideal to collect the necessary information to determine whether a patient is stable or in need of emergent intervention. Ultimately in veterinary medicine most commonly our triage is into categories of emergent and stable.

Who should triage patients? Ideally, individuals that have some degree of medical expertise should be triaging patients. That should be a person who knows enough about what is normal to recognize abnormal. While it does not always have to be a CVT, if it is not at least a CVT then the individual should be heavily trained in this position to make sure that they are able to recognize emergent situations and respond accordingly.

When should patients be triaged? In fact, patients can be triaged at every stage of their interaction with your hospital. Phone triage can help to ascertain whether a patient should be scheduled into a regular appointment when one is available, squeezed in or dropped or dropped off as an emergency, or taken immediately to an emergency referral facility. All staff members should be trained to recognize those triggers for immediate assessment and communicate with the rest of the veterinary team accordingly when those patients are coming in for assessment. Triage continues once medical orders have been generated where those patients in greatest need should continue to be prioritized over stable patients.

If ever the person doing the triage is in doubt, a patient should be triaged as critical so that a rapid assessment can be completed to investigate stability more closely. If the patient appears to be stable after all there is no reason why it cannot wait with its owner after stability has been established. Do not forget that patient condition can change over time – if things change it is okay to repeat a triage for a patient, triage status may or may not change as well.

At all times remember that your hospital is a team and triage is an imprecise art, not actually a hard and fast science. Everybody should work together to ensure that your

patients are cared for as well as possible. Patients may require more than one triage through a visit and their triage status can change. What one person may be worried is emergent might not seem as serious to another individual. Do not forget that even in the science of human triage, sometimes the recommendation is just to go with the responder’s gut feeling. The gut is not always right in this regard but for a lot of cases that come through the doors of a veterinary clinic there is not a right or wrong answer.

You might be thinking to yourself, “I work at a daytime practice, I don’t really need triage” but realistically, you triage everything that you do all day long. In the event that there are plenty of resources to manage everything that needs to be done immediately, it is true that triage is not necessary. In the real world, emergent and unscheduled patients come in frequently in daytime practices. Tasks get set aside to complete at a time when there are not patients waiting. Tasks for stable patients get set aside to complete tasks for more emergent patients.

As a veterinarian and a manager, I triage constantly. When there are sick patients coming through the door, they come first. When there are lags in patient flow, then I can manage client communications. When there are no more client communications needed, I can work on my medical charts. If there are no patients, no clients to talk with, and my medical charts are all caught up then I can work on things like lecture notes or other managerial tasks! Sometimes I have to make adjustments in that flow. Imagine, for example that a patient that just walked out my doors is headed to their regular veterinarian. Now I have an urgent need to complete and transmit that medical chart so that the regular veterinarian knows what I have done with the patient and what conversation I have had with the pet owner. Every moment of my work day I am triaging what is most important to get done next and it is usually only the rarest of rare rainy winter nights where I make my way to art therapy as my most important task.

Today, we triage patients and tasks regularly throughout our day. Future directions for veterinary medicine may include triaging stable patients to a different type of facility such as an urgent care or daytime veterinary practice. Currently we lack the infrastructure in veterinary medicine for this type of cross facility cooperation but this could change in the future. More often emergency veterinary facilities are also offering urgent care style appointments where an emergency appointment can be booked by an owner after phone or physical triage to determine whether the patient’s concerns are stable vs emergent. Further growth in this direction could help with redistribution of resources and reduce the stress on our abilities to respond quickly when faced with a higher load of critical patients. There are potential risks with this approach that have made it a slow growing field – primarily liability associated with changes in triage status or health concerns that do not always make themselves apparent at the time of triage.