“Triage is not a place for the inexperienced or the indecisive.”
Thom Mayer and Kirk Jensen, Hardwiring Flow: Systems and Processes for Seamless Patient Care
A pitfall of nurse triage education is cognitive shortcuts (heuristics). Examples include “representative restraint,” “premature anchoring,” and age and gender bias.
Representative restraint is the concept that if it does not fit the pattern, so it cannot be “X.” This problem occurs when a practitioner only recognizes prototypical presentations while dismissing the atypical. Triage examples include ruling out
- Atypical acute coronary syndrome presentation when a patient is younger than usual or complains of left elbow pain
- Appendicitis when there is no fever at presentation
Premature anchoring is another cognitive shortcut that can be problematic during triage. Premature anchoring occurs when a person fixates on certain features, such as constipation in an elderly person complaining of abdominal pain, without further consideration of other possible causes.10
Age and gender biases create potential for dangerous triage to less acute levels than appropriate. These biases are examined in multiple published works and another example of triage-related heuristics.
Misclassifications will occur with any triage system. Experts fully expect that intuition, balanced by evidence-based practices, is used to make triage acuity decisions without the benefit of in-depth evaluation or diagnostic studies. The accuracy of a triage decision, therefore, should be measured against the type and extent of subjective and objective findings (minimum data set) that another experienced triage nurse would elicit and factor into a decision.
Newer flow models quickly assign patients to higher or lower acuity triage areas as needed, followed by transfer of care between locations or department tracks, if needed. When triage has not been fully accurate, the tendency has been to blame the triage nurse and refer to these instances as “mistriages.” In some split-flow models, the provider in the intake area performs an expanded triage function and splits ESI Level 3 patients into categories of high (resource) 3s and low (resource) 3s with those patients in the high 3 category streamed to the main ED.
The primary purpose of triage is to identify patients acutely in need of life-, limb-, or organ-saving intervention. Most newer front-end systems place a highly skilled, experienced nurse at the first point of contact. It does not make sense for the back end to have a charge nurse, but not the front end, where all of the risk resides. Undifferentiated patients entering the ED and needing attention should have a highly skilled person as the point of first contact. This “quick look” nurse is charged with performing a rapid assessment based on appearance, chief complaint, and possibly vital signs.
The secondary goal after identifying emergent cases is to stream patients to the location using the process that will be most efficient for their needs (Figure 31-3).
Efficient streaming of patients.
Advanced ED operational configurations segment patients into streams of patients who are likely to need the same types of testing and treatment. The need for different segmentation schemes is largely driven by volume and acuity, although other factors such as trauma and teaching designation have a role in determining the number and types of different treatment pathways. The minimum amount of information is literally patient appearance and chief complaint.
Vital signs are helpful but not necessary for streaming, except when the segmentation scheme is based on ESI levels. After the quick-look assessment, if the patient does not look ill, the next question becomes,
“What is the best place for this patient to receive high-quality, efficient care?”
These advanced triage systems are designed with specific areas for
- Patients who need basic care and are likely to go home (low-acuity, vertical patients)
- Patients who need more significant diagnostics and interventions (mid-acuity, vertical patients)
- Patients who are likely to need intensive evaluation and management (high-acuity, horizontal patients)
As previously mentioned, the volume and acuity mix of an ED will largely determine how many patient segments are practical. For example, an ED that typically experiences 40,000 high-acuity patient visits a year will not need a triage-based low-acuity treatment area (super track), but could almost certainly benefit from an intake team of a physician and mid-level provider in triage because of the low numbers of ESI Level 4 and 5 patients (1.2-1.4 patients per hour at peak times) and the high numbers of ESI Level 3 patients.
Likewise, an ED with typically 40,000 low-acuity patient visits annually would have the volume to support a super track with a peak arrival rate of 3 to 4 ESI Level 4 and 5 patients per hour (Figure 31-4).
Low-acuity ED volume relating to super track.
One very important point and a potential pitfall with segmentation is that oversegmentation can negatively affect flow. For instance, if an ED has separate pediatric, adult, fast-track, and psychological patient areas, it is likely that at any given time, providers in some areas are idle while patients are experiencing queues waiting for providers in other areas. It is important to develop proper segmentation based on volume and acuity to ensure smooth flow and efficient use of staff.