emory pediatric emergency medicine

Emory Pediatric Emergency Medicine

http://pediatrics.emory.edu/pem

Prioritizing Patient Care in an Era of Overcrowding

Naghma S. Khan, MD

Pediatric Emergency Medicine

Emory University School of Medicine

Children’s Healthcare of AtlantaJune 5, 2009

3

Introduction

ED Challenges• Overcrowding• Space constraints• Nursing and physician shortage• Increasing non-urgent patient volumes in the ED• Decreasing reimbursement

Triage methods through the ages• Three-tier• Five-tier

Emergency Severity Index (ESI) Triage• Agency for Healthcare Quality Improvement

4

Gaining capacity

Build a larger ED• Cost - $$$$• Space• 5-10 year plan – predictions fall short

Decrease throughput• Turnover rooms with greater frequency• No added cost• Decreased walk-out rates – increased revenue• Improved patient satisfaction• Increased capacity

5

Impact of throughput times on ED capacity

6

ED Flow

Input Throughput Output

Emergency CareSeriously ill from the community and referral sources

Unscheduled Urgent CareLack of available ambulatory careDesire for immediate care

Safety Net CareVulnerable populationsAccess barrier

Demand for ED care

Ambulance diversions

Patient arrives to ED

Triage and room placement

Diagnostic evaluation and

treatment

ED boarding of inpatients

Ambulatory Care System

Transfer to outside facility

Admit to hospital

Left without being seen

Patient Disposition

Lack of access to follow-up care

Lack of available staffed inpatient beds

COURTESY ACEP

7

ED Overcrowding!





Demand for ED care



Triage and room placement


treatment




Admit to hospital


Patient Disposition



COURTESY ACEP

8

The Need to Prioritize





Demand for ED care




treatment




Admit to hospital


Patient Disposition



COURTESY ACEP

Triage and Room Placement

Triage and Room Placement

9

Triage

French verb “trier” - to separate, sort, sift or select Prioritization of patients based on the severity of illness/ injury

Here’s a copy of our new triage plan…..the order is “walking wounded” first, the dying and dead second, lawyers last…….

10

Food for thought

Ultimate Goal• Get the patient to a doctor

Is triage (sorting) necessary if there is a bed, a doctor and resources available and no wait?

Is a nurse assessment essential for ALL patients

11

The History of Triage

12

History

Napoleonic Wars (early 1800’s)– Battlefield Triage• Likely to live, regardless of care• Likely to Die, regardless of care• Immediate care would make a positive difference

Evolution over time• Pre-hospital triage• Mass Casualty triage• Managing ED inflow• Telephone triage/ medical advice lines

13

Introduction of Triage to U.S.A

1950’sOffice-based practiceAfter hours primary care to ED’s Increase in low acuity use of ED’sOvercrowdingNeed to sort sick from non sickMilitary physicians and nurses

introduce triage

14

Maturation

Traffic Director• Non-clinical person assessing arrivals and directing to

appropriate areas

Spot check• Realization that non-clinicians are inadequate to assess

patients• Used in low volume ED’s• Clerk watches ED entrance and pages the triage RN when

needed

Comprehensive • Experienced nurses• Rapidly gather “sufficient” information to determine acuity• Within a 2 to 5 minute time frame – in reality this goal is

met 22% of the time

15

Comprehensive Triage

Takes longer to triage “extremes” of age Definite benefits

• Each patient is greeted by an experienced nurse

• A sick patient is immediately identified• First aid is provided as needed• The nurse is available to meet the

emotional needs of the patients and families in the waiting room

16

Triage Nurse

Triage nurses require advanced clinical decision making expertise

They need to • Make complex clinical decisions, in conditions of

uncertainty with limited or obscure information, in minimal time

• Have limited margin for error• Be able to rapidly identify and respond to actual life-

threatening states• Be able to make a judgment on the potential for life-

threatening deterioration

17

Triage

Decisions are made• In response to presenting signs or symptoms• No attempt is made to formulate a medical

diagnosis • Triage category is allocated based on the necessity

for time-critical intervention to improve patient outcome, potential threat to life or need to relieve suffering

• The accuracy of triage decisions is a major influence on the health outcomes of patients

18

Triage Nurse

19

ED Triage Goals

• To sort a group of patients who present simultaneously to the ED

• To ensure Appropriate care Appropriate location Appropriate degree of urgency

• To initiate care in response to clinical need rather than order of arrival

• To promote safety by ensuring that timing of care and allocation of resources matches the degree of illness or injury

20

Triage Outcomes

Expected triage – triaged appropriately• Seen by a doctor within a suitable time frame and should

have a positive health outcome

Over triage – triaged to a higher level then indicated• This decreases the wait time for the patient, which is not

detrimental to the patient, however the inappropriate allocation of resources has the potential to adversely affect other patients

Under triage – triaged to a lower level then indicated• This prolongs the wait time until medical intervention and

there is potential for deterioration or prolongation of pain and suffering. These factors increase the risk of an adverse patient outcome

21

USA Triage Protocols

Maclean: 2001 survey of 27% of all ED’s in the United States• 69% used 3-Tier Triage• 12% used 4-TierTriage• 3% used the Australian or Canadian 5-Tier Triage• 16% did not use a scale or did not answer

National Center Health Statistics: 2003• 47% used 3-Tier Triage• 20% 4-Tier Triage• 20% 5-Tier

22

3-Tier

Levels• Emergent: Poses an immediate threat to life or

limb• Urgent: Requiring prompt care, but can wait

“hours”• Non-Urgent: Condition needs attention, but time is

not a critical factor Large variation in definition for each level by hospital No clear correlation with disposition Large volume of “urgent” patients – with varying

degrees of illness

23

Reliability of 3-Tier Triage

Wuerz, Fernandes, Alarcon – 1998• Triage nurses and EMT’s at 2 hospitals• Rated the acuity of 5 scripted patient scenarios

using 3-tier scale• Same people repeated the triage assignment 6

weeks later• Only 24% rated all 5 cases the same in both

phases• Overall kappa (inter-observer variability) statistic

was 0.35 (0: no agreement; 1: perfect agreement)

• 3-Tier not reliable, not effective

24

Four-Tier Acuity Scales

Blue – Red – Yellow – GreenAttempted to split the 3-tier “red” and

“yellows”More equitable distribution of patients

across the levelsRequires a high degree of nursing

experience to do accuratelyPoor reliability and reproducibility

25

Five-Tier Triage

Australasian National Triage Scale – 1994 “This patient should wait for medical assessment and treatment

no longer than ____ minutes”

Correlates strongly with • Resource consumption• Admission rates• ED length of stay• Mortality rates

Used as a basis of ED assessment and quality of care – patients need to be seen within the triage assigned time

26

Quality Goals

ATS Category Time to Doctor Compliance Goal

ATS 1 Immediate 100%

ATS 2 10 minutes 80%




27

Manchester Triage – 1997

Ascertain patients chief complaint Select 1 of 52 flow charts with an algorithm that

assigns a triage score of 1 to 5 based on a structured interview

Reliability study comparing nurse triage to senior medical staff triage• Fair to Moderate reliability

Time to doctor• 1 Immediate 0 minutes

• 2 Very Urgent 10 minutes

• 3 Urgent 60 minutes

• 4 Standard 120 minutes

• 5 Nonurgent 240 minutes

28

Canadian Triage and Acuity Scale (1996)

Pediatric Modifications Initial impression of severity of illness Evaluation of presenting complaint Assessment of behavior and age related physiological

parameters Limited assessment for assigning Level 1 or 2 Full assessment for 3,4,5 Quality goal: to see a high percentage of patients in

each category in the specified time

29

Time factors

• Used for quality•Allows acuity adjusted comparison of ED’s•Used for predicting staffing models for physicians and staff

30

Table 1: Suggested time goals, fractile response rates and admission rates by triage level

TRIAGE LEVEL

I II III IV V

Time to care

Immediate 15 mins 30 mins 60 mins 120 mins

Fractile Response

98% 95% 90% 85% 80%

Admission Rates

70%-90% 40%-70% 20%-40% 10%-20% 0%-10%

31

Outcomes

Strong correlation for admissions Inter-rater reliability high

• Physician and RN: Kappa 0.85• Physician, RN and Paramedic: Kappa 0.77

Used by paramedics for pre-hospital triage Used for staffing predictions

• Time spent by physician for each triage level Used for evaluating practice variability Is a country-wide measure of timeliness of service

32

The Emergency Severity Index

Wuerz and Eitel – 1998 Fundamentally the closest to when triage originated Principal goal of triage is to facilitate prioritization of patients

based on the urgency of the condition• Which person is seen first• How many resources will they require

Patient sorting + patient streaming Underlying assumptions of the 1st 3 5-tier systems was “how long

can the patients wait There is no time allocation in ESI Dying patient - see immediately Sick appearing patient- “shouldn’t wait” The lower 3 levels are categorized based on resource needs

33

11

22

33

4455

no

no

no

yes

yes

abnormal

34

Decision Point A

Is the patient dying

•Needs an immediate airway, medication, or other hemodynamic intervention•Is already intubated, apneic, pulseless, severe respiratory distress, SpO2 < 90 percent, acute mental status changes, or unresponsive

35

Decision Point B

Should the patient wait?

• Is this a high-risk situation?• Is the patient confused, lethargic or disoriented?• Is the patient in severe pain or distress?

36

Decision Point C

Resource Needs

•To identify resource needs, the nurse needs to be familiar with ED standards of care – EXPERIENCE!

37

Decision Point D

The Patient’s Vital Signs

•If out of range upgrade 3 to 4

38

Decision Point: Pediatric Fever

Fever

•Recommendation: Check temp <3 years at triage

39

Five-Tier Acuity Rating Scales

Widespread use of ESI in the United States Canadian and US nurses studied together – randomized to ESI

and CTS– Kappa for ESI 0.89– Kappa for CTS 0.91

Advantages Easy to learn and implement High degree of inter-rater reproducibility and reliability

– Kappa 0.88 Ability to predict hospitalization, resource utilization, ED

length of stay and six-month mortality Moderate correlation with physician E/M codes and nursing

workload Facilitates meaningful comparison of case mix between

hospitals

40

ESI data at Children’s

1 2 3 4 5

Site 1 Admits

92.2% 43.4% 13.1% 0.9% 0.3%

Site 2 Admits

88.6% 37.2% 14.1% 1% 0.3%

41

In summary

The goal of an ED visit is to see a physician The goal of triage is to prioritize patients so

• The sickest patients can be seen expeditiously• The non-urgent patients can be separated and seen in a low

acuity setting

emory pediatric emergency medicine

Documents

ed triage

prioritizing patient

ed overcrowding

rooms ed throughput

hours ed capacity

ed diagnostic evaluation

larger ed cost

introduction ed challenges